Should we modify our indications after the EVAR-2 trial conclusions?

Background: To compare the results of the endovascular aneurysm repair (EVAR) in patients considered as unfit for surgery in a "high volume" center with the EVAR-2 trial results.

Methods: In our center, between January 2006 and December 2008, 469 endovascular aorta treatments were performed in high-risk patients. All the data were prospectively collected in a database. Among 469 patients, we selected 191 patients considered as unfit for open surgery (group 1) corresponding to the EVAR trial criteria. Variables such as postoperative mortality at 30 days and 1 year, complications rates, as well as early and late redo surgery were evaluated. Long-term pharmacological treatment before surgery was listed. These results were compared with the EVAR trial (group 2). Survival during the follow-up was calculated according to the Kaplan-Meier method.

Results: Mortality at 30 days was 1.6% and 9% in groups 1 and 2, respectively (p = 0.002). Global complication rate was 44% and 43% in groups 1 and 2, respectively (p = 0.52). Over the follow-up period, the redo surgery rate was 13% and 26% in groups 1 and 2, respectively (p = 0.0102). In our cohort, the survival rate at 2 years was 84% with a residual number of 102 patients. Before surgery, a long-term antiplatelet treatment was prescribed in 89% and 58% of the patients and statins in 74% and 39% of the patients in groups 1 and 2, respectively (p < 0.0001).

Conclusion: The EVAR-2 trial conclusions are in opposition to the practice of French vascular surgeons. Endovascular treatment of abdominal aortic aneurysms in high-risk patients is justified. This study confirms the importance of a multidisciplinary treatment for high-risk patients in high-volume centers.