Endovascular aneurysm repair for symptomatic abdominal aortic aneurysms has comparable results to elective repair in the long term

Objective: Endovascular aneurysm repair (EVAR) has been extensively study regarding elective and ruptured abdominal aortic aneurysm (AAA) repair. However, much less is known about EVAR of symptomatic nonruptured AAA, especially concerning the long-term results. The aim of this study was to assess the outcomes of EVAR of symptomatic AAA compared with asymptomatic AAA at a tertiary center using a single graft. Methods: All consecutive patients treated for symptomatic and asymptomatic AAAs from 1998 to 2012 at our institution, using the Cook Zenith stent graft (Cook Europe NS, Bjaeverskov, Denmark), were included in the study. Ruptured AAAs were excluded. Patients' charts were reviewed to obtain preoperative, intraoperative, and postoperative data. All available imaging was reviewed. Life tables were constructed to assess for overall and late AAA-related survival, clinical success, and endoleak freedom. Results: There were 680 patients included (137 symptomatic AAAs). No difference in technical success rate (96.1% for asymptomatic AAAs vs 94.9% for symptomatic AAAs) was present (P=.477). Thirty-day mortality was more common in symptomatic AAAs (6.6% vs 1.5% for asymptomatic AAA5; P=.002). Freedom from reinterventions was 72% 3% for asymptomatic AAAs vs 73% 5% for symptomatic AAAs (P=.785) at 10 years postoperatively. There was no difference in primary (P=.300) or secondary (P=.099) clinical success between groups, although there was higher assisted clinical success (P=.023) for asymptomatic AAAs compared with symptomatic AAAs. Persistent late clinical failure was similar in both groups (14.2% for asymptomatic AAAs vs 15.3% for symptomatic AAA5; P=.732). Freedom from late AAA-related death was higher (P=.016) for asymptomatic AAAs compared with symptomatic AAAs, but the differences disappeared when the first 30 days were disregarded. Overall survival (P=.687) was similar in both groups. An adequate aneurysm neck preoperatively conferred a better outcome in end points including overall survival. Conclusions: Symptomatic AAAs have an almost quadrupled 30-day mortality compared with asymptomatic AAAs, but the outcome differences fade in the long term. An adequate aneurysm neck was associated with better outcomes including overall survival independent of the initial presentation of the AAA. These results suggest the need of improving the identification of sym ptomatic patients requiring preoperative medical optimization. However, this is often limited by the acute need of the procedure, and more intensive postoperative monitoring may have greater potential. Independently, a strict anatomic selection for infrarenal EVAR is of paramount importance for the long-term outcome.