Surgical Grand Rounds: EVAR, FEVAR, and Open Repair: What to make of alphabet soup

Presented by Amanda Fobare, MD, Chief Resident

Department of Surgery, Emory University School of Medicine

February 27, 2020


The evidence: EVAR vs. open repair for elective AAA repair: 

  • EVAR 1 – Endovascular Aneurysm Repair Trial 1 (UK)- Lancet (2005, 2016)
  • DREAM – Dutch Randomized Endovascular Aneurysm Management Trial (Netherlands & Belgium)- NEJM (2004), JVS (2017)
  • OVER – Open versus Endovascular Repair Trial (USA)- JAMA (2009), NEJM (2012)


What to make of alphabet soup: 

  • Infrarenal Aneurysms:
    • EVAR can be done safely, can be done at smaller hospitals/lower volume, need long term follow up
    • Watch out for the neck!
    • Open repair can be done safely, but there is evidence that surgeon and hospital volume matter
  • Complex Aneurysms:
    • More surgeons are tackling these operations at both academic and community institutions
    • PMEGs vary by institution
    • FEVARs should likely be done at high volume centers by high volume surgeons

Take-away points:

  • Cost: Should we standardize the cost of endografts?
  • Access: If we limit lower volume hospitals and/or surgeons, will we limit access
  • PMEG vs. Custom made devices: Can we standardize results?
  • Vascular Quality Initiative
  • Collaboration between hospital and surgeons
  • Reliance on attendings and senior partners to be master teachers

Articles referenced by Dr. Fobare during her presentation: 

Elkin DC. ANEURYSM OF THE ABDOMINAL AORTA: TREATMENT BY LIGATION. Ann Surg. 1940 Nov;112(5):895-908.

Patel R, Sweeting MJ, Powell JT, Greenhalgh RM; EVAR trial investigators. Endovascular versus open repair of abdominal aortic aneurysm in 15-years’ follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet. 2016 Nov 12;388(10058):2366-2374.

EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005 Jun 25-Jul 1;365(9478):2179-86.

Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, Buskens E, Grobbee DE, Blankensteijn JD; Dutch Randomized Endovascular Aneurysm Management (DREAM)Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004 Oct 14;351(16): 1607-18.

van Schaik TG, Yeung KK, Verhagen HJ, de Bruin JL, van Sambeek MRHM, Balm R, Zeebregts CJ, van Herwaarden JA, Blankensteijn JD; DREAM trial participants. Long-term survival and secondary procedures after open or endovascular repair of  abdominal aortic aneurysms.J Vasc Surg. 2017 Nov;66(5):1379-1389. Erratum in: J Vasc Surg. 2018 Feb;67(2):683.

Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT Jr, Matsumura JS, Kohler TR, Lin PH, Jean-Claude JM, Cikrit DF, Swanson KM, Peduzzi PN; Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.JAMA. 2009 Oct 14; 302(14):1535-42.

Lederle FA, Freischlag JA, Kyriakides TC, Matsumura JS, Padberg FT Jr, Kohler TR, Kougias P, Jean-Claude JM, Cikrit DF, Swanson KM; OVER VA Cooperative Study Group. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm.N Engl J Med. 2012 Nov 22;367(21):1988-97.

Zettervall SL, Schermerhorn ML, Soden PA, McCallum JC, Shean KE, Deery SE, O’Malley AJ, Landon B. The effect of surgeon and hospital volume on mortality after open and endovascular repair of abdominal aortic aneurysms. J Vasc Surg. 2017 Mar;65(3):626-634.

Hospitals Move to Limit Low-Volume Surgeries (U.S. News & World Report, 05/19/2015)

Greenberg RK, et al. Should patients with challenging anatomy be offered endovascular aneurysm repair? J Vasc Surg. 2003 Nov;38(5):990-6.

Simons JP, et al. Trends in use of the only Food and Drug Administration-approved commercially available fenestrated endovascular aneurysm repair device in the United States. J Vasc Surg. 2017 May;65(5):1260-1269.

O’Donnell TFX, Patel VI, Deery SE, Li C, Swerdlow NJ, Liang P, Beck AW, Schermerhorn ML. The state of complex endovascular abdominal aortic aneurysm repairs in the Vascular Quality Initiative. J Vasc Surg. 2019 Aug;70(2):369-380.

Dossabhoy SS, Simons JP, Flahive JM, Aiello FA, Sheth P, Arous EJ, Messina LM, Schanzer A. Fenestrated endovascular aortic aneurysm repair using physician-modified endovascular grafts versus company-manufactured devices. J Vasc Surg. 2018 Jun;67(6): 1673-1683.

Gupta AK, et al. Real-world cost analysis of endovascular repair versus open repair in patients with nonruptured abdominal aortic aneurysms. J Vasc Surg. 2020 Feb;71(2): 432-443.e4.

Chow WB, Leverentz DM, Tatum B, Starnes BW. Fenestrated endovascular aneurysm repair is financially viable at a high-volume medical center with positive hospital contribution margins and physician payment.J Vasc Surg. 2020 Jan;71(1):189-196.e1.

Locham S, Faateh M, Dhaliwal J, Nejim B, Dakour-Aridi H, Malas MB. Outcomes and cost of fenestrated versus standard endovascular repair of intact abdominal aortic aneurysm in the United States. J Vasc Surg. 2019 Apr;69(4):1036-1044.e1.

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