We read with interest Mr Armon's letter and we agree with his notion that the pendulum may have already swung too far in some instances in favour of endovascular aneurysm repair (EVAR). We're all witnessing irrational use of EVAR and subsequent bad outcomes related to poor patient/anatomy selection. However, this cannot justify abandonment of EVAR. This is a good reason to initiate measures for the appropriateness of care, and to monitor and inform users of their poor anatomy selection or outcomes (outliers amongst their peers) through the existing quality initiatives (e.g. vascular quality initiative in USA,
1
German AAA registry,2
etc.). If we all agree that EVAR first is the best strategy for anatomically suitable ruptured cases, then we must accept that EVAR only for ruptures has not been tested and is probably not a realistic option.As far as retaining our open skills is concerned, this has been addressed extensively in the literature and centralisation of complex open aneurysm repair is not an unreasonable consideration.
3
Still, in an otherwise balanced vascular practice, with a rational EVAR first strategy there will be an appropriate number of open cases to keep surgeons competent.Finally, regarding patient choice, it is indeed eventually the surgeon's choice depending on how facts are presented (inherent bias). The truth is however, that existing Society for Vascular Surgery
4
and European Society for Vascular Surgery5
guidelines represent rigorously analysed data and can help resolve our biases. It is difficult to argue against them.The opportunity to emphasise the advantages of both open and endovascular surgery swinging the pendulum towards a more balanced approach remains open.
REFERENCES
- Open and endovascular aneurysm repair in the society for vascular surgery vascular quality initiative.Surgery. 2017; 162: 1195-1206
- Trends in patient safety of intact abdominal aortic aneurysm repair: German Registry Data on 36,594 procedures.Eur J Vasc Endovasc Surg. 2017; 53: 641-647
- Outcomes after ruptured abdominal aortic aneurysm repair in the era of centralized care.J Vasc Surg. 2019; : 1-14
- The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67 (e2): 2-77
- European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93
Article info
Publication history
Published online: January 30, 2020
Accepted:
January 6,
2020
Received:
December 17,
2019
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© 2020 European Society for Vascular Surgery. Published by Elsevier B.V.
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