The rationale for lowering the size threshold in elective endovascular repair of abdominal aortic aneurysm

The current size threshold for elective abdominal aortic aneurysm (AAA) repair is 5.5 cm. Over this diameter limit, the AAA rupture rate exceeds the perioperative mortality of open surgical repair. Endovascular aneurysm repair (EVAR) is associated with lower perioperative mortality rates, so it seems logical to hypothesize that the size threshold for endovascular AAA repair should be lowered. The arguments supporting this proposal are: (1) the EVAR-associated mortality rises several fold with increasing age, (2) larger AAAs have more complex anatomy that may not be suitable for EVAR, and (3) smaller AAAs treated with EVAR have lower perioperative and long-term mortality and fewer secondary interventions. Future guidelines may need to consider lowering the size threshold for elective AAA repair in the endovascular era in certain patient subgroups. The reduction of the size threshold should be counterbalanced against the cost of the procedures, as well as the age, life expectancy, and general condition of the patient.