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The Evolution of EVAR: Has Surgical Techniques Improved with Increasing Experience?
Jeffrey Jim, MD1, Jason T. Lee, MD2, Luis A. Sanchez, MD1.
1Washington University School of Medicine, St Louis, MO, USA, 2Stanford University Medical Center, Stanford, CA, USA.

Objective: Since approval over a decade ago, endovascular aortic aneurysm repair (EVAR) has been widely adopted for treatment of abdominal aortic aneurysms. Recent reports have suggested worsening patient outcomes since advent of the therapy. The goal of this study is to determine if surgical techniques and subsequent patient outcomes have improved with increasing experience with EVAR.
Method: Patient demographics, aneurysm morphologies, perioperative data, and procedural endpoints were evaluated in 166 patients enrolled in the two identical clinical trials: eLPS trial (2002-03) and 93 patients from the Vitality trial (2008-09).
Results: While the mean age of patients in the two trials were similar, there was a higher proportion of women (20.4% vs 8.4%, P<0.02) and patients with higher SVS risk scores (P<0.001) in Vitality. Aortic neck diameter was smaller for Vitality patients but there were no differences with aortic neck length or maximum aneurysm diameter. In Vitality, there was more frequent use of general anesthesia (79.6% vs 40.4%, P<0.001), shorter procedure duration (105.5 vs 167.3 min, P<0.001), less blood loss (200 vs 250 mL, P<0.001), and fewer extension components required (45.7% vs, 59.3%, P<0.05). For patient outcomes, there were similar clinical success (95.1% vs. 94.6%) and mortality (1.9% vs 0%) rates at 30 days. Furthermore, 30-day freedom of major adverse events (88.9% vs. 95.7%) was low in both studies and there was no difference in the rate of major type I/III endoleaks.
Conclusions: In comparing two identical EVAR clinical trials set six years apart, there were significant improvements in procedure technique with continued excellent clinical outcomes. Further follow-up is necessary to determine if increased physician experience leads to improved long-term outcomes and provide significant cost reduction.


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