Should the role of EVAR be re-evaluated in light of the 10 year results of EVAR-1?

EVAR-1 published its 10 year results in 2010. The principal finding of the study was that the endovascular group (EVR) had a significant reduction in early aneurysm related mortality compared to open surgery (OR), but the benefit was lost by the end of the study (adjusted hazard ratio [HR], 0.92; 95% confidence interval [CI] 0.57-1.49; P=0.73). By the end of follow-up, there was no significant difference between the OR and EVR group in terms of death from any cause (HR 1.03; 95% CI 0.86-1.23; P=0.72). Despite these findings the uptake of EVR continues to increase. EVR is driving improved surgical outcomes in elective abdominal aortic aneurysm (AAA) surgery, and may yet establish itself as an essential tool in the emergency setting. Elective AAA mortality may be reducing in the U.K. as a consequence of broader application of EVR. This article presents and examines the EVAR-1 data and reports the additional wealth of evidence supporting EVR from prospective registries. It proposes that EVR should be re-evaluated, but not as a consequence of the long-term EVAR-1 results. Clinicians' expertise, understanding and the technology of EVR have progressed significantly since the establishment of the EVAR-1 trial, such that the results, though valuable, may not translate to modern practice. It is essential to maintain excellence in vascular surgery and the evidence-base now demonstrates that best practice in AAA management is in specialist vascular centres, performing high volume surgery offering EVR to all patients who are morphologically suitable.