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PVSS9. Should Endovascular Repair Treatment Threshold Be Expanded For Small Abdominal Aortic Aneurysms?

Christopher J. LeCroy, Marc A. Passman, Steven M. Taylor, Mark A. Patterson, Bart R. Combs, William D. Jordan, Jr.
University of Alabama at Birmingham, Birmingham, Ala.

OBJECTIVES: Size recommendations for treatment of infrarenal abdominal aortic aneurysm (AAA) have been established based on risk of surveillance versus open repair. Although reported operative morbidity and mortality for endovascular repair is reduced compared to open repair, the role of endovascular repair for smaller AAA is less defined, and outcomes data in this sub-population is lacking.

METHODS: All patients undergoing endovascular AAA repair between 2000 and 2006 with various stent graft designs were identified from a prospective vascular surgery registry, and those with maximal diameter 4.0 to 4.9 cm form the small AAA study population. Data was analyzed for indications, co-morbid medical problems, stent graft type, technical factors, peri-operative morbidity and mortality, change in AAA size on follow-up imaging, and long-term aneurysm-related complications and mortality. Life-table methods were used as per reporting standards.

RESULTS: Over the 7 year period, there were 743 endovascular AAA repairs, of which 133 (17.9%) were performed for small AAA. Peri-operative complication rate was 9.0% including mostly cardiac related problems. Endovascular stent graft related complications included endoleak 21.1% (Type I=1, Type II=25, Type III=2), and graft limb thrombosis 0.8%. There were no stent graft migrations. AAA size was unchanged or decreased in 81% of patients (mean decrease 7.5 mm±5.8 mm), increased in 15% (mean increase 3.9 mm±4.7 mm) and unable to be determined in 4% (mean imaging follow-up 27 months±20 months). Freedom from aneurysm sac expansion was 96% at 1 year, 86% at 3 years, and 77% at 5 years (standard error (SE)=6.8%). Overall survival was 98%, 93%, and 84% at 1, 3, and 5 years, respectively (SE=5.6%). Peri-operative 30-day mortality was 0.8% with an aneurysm-related mortality of 1.5% at 5 years (SE=2.6% at 5 years). There were no deaths from delayed aneurysm rupture.

CONCLUSIONS: Endovascular repair of small AAA is associated with low peri-operative morbidity and mortality compared to published results for open repair. Considering reduced morbidity and mortality for endovascular repair of small AAA, treatment threshold can be reduced to 4 cm in selected patients.