Greater Than The Sum Of Its Parts: How Endovascular Aneurysm Repair (EVAR) Was Born From Open Surgical Repair And Trans-femoral Angiography
Sarah L. Wright1, Jacquelenn M. Stuhldreher, MD2, Nathanial Fernandez, MD3, Samantha Cox, DO4, Romeo C. Ignacio, MD5.
1Uniformed Services University, Bethesda, MD, USA, 2Naval Medical Center Portsmouth, Portsmouth, VA, USA, 3Naval Medical Center San Diego, San Diego, CA, USA, 4PH-USC Medical Group Vascular Surgery, Columbia, SC, USA, 5Rady Children's Hospital San Diego/University of San Diego School of Medicine, San Diego, CA, USA.
OBJECTIVES: Outline historic milestones in the development of EVAR as the predominant surgical treatment of abdominal aortic aneurysms (AAA), focusing on both open and angiographic influences. Illustrate how techniques of the past continue to impact the future of primary EVAR and reintervention.
METHODS: Literature describing advances in AAA repair throughout history was reviewed. Primary articles were acquired for novel techniques and cases described.
RESULTS: AAA repair began with open ligation of the aorta by Antyllus in the 2nd century AD. Further operations of varying success occurred over the next several centuries including the first aortic ligation for an external iliac artery aneurysm by Cooper in 1817. Dubost performed the first resection and replacement of an abdominal aortic aneurysm with an aortic homograft in 1951 as an alternative to the cellophane wrapping and electrothermic coagulation that was common practice at the time. Introduction of polymeric sealants for vascular applications occurred shortly thereafter. Ultimately, open synthetic aortic grafting was implemented and served as the dominant practice for several decades.
Concurrently in the 20th century, surgeons and interventionalists pioneered advances in angiography. Brooks performed the first femoral arteriogram in 1923 prior to a lower extremity amputation. Translumbar aortography was introduced by Dos Santos in 1929. Seldinger's technique of catheter replacement over a wire, described in 1953, further contributed to adoption of angiographic methods within medical and surgical communities.
Open surgery and angiographic techniques were integrated by Parodi in 1990, with performance of the first EVAR. Subsequently, the paradigm of AAA management has shifted to include both complex endovascular and open procedures as viable options for treatment of AAA.
CONCLUSIONS: The inception of EVAR from open and angiographic practices has forever altered the clinical approach to AAA management. Though many techniques have been replaced over time, some, particularly embolization and the use of surgical sealants, have returned as adjuncts to treat endoleaks or improve primary repairs. A thorough understanding of the history of AAA repair can provide clinicians with insight into creative solutions to improve outcomes of both endovascular and open techniques.
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