The traditional surgical treatment of AAA involves direct exposure of the aneurysm through a long abdominal incision, interruption of aortic flow, and the creation of sutured connections (anastomoses) between the ends of a fabric tube (graft) and the nondilated blood vessels above and below the aneurysm. Endovascular repair substitutes trans-femoral arterial access for trans-abdominal access, expanding metal cylinders (stents) for anastomotic suture lines, and fluoroscopic imaging for palpation and inspection. The endovascular prosthesis serves as an internal bypass, isolating the aneurysm from the circulation, and producing reductions in aneurysm pressure , size, and risk of rupture. Failure to exclude the aneurysm is evidenced by contrast-enhanced blood between the stent-graft and the wall of the aneurysm, i.e. endoleak [9,10]. Some stent-grafts also produce a phenomenon known as endotension, in which the aneurysm dilates in the absence of endoleak . These endograft failures (endoleak and endotension), by leading to aneurysm dilation, substantially increase the risk of aneurysm rupture.
Compared to open surgery, endovascular repair causes less physiological derangement [12,13], perioperative mortality, perioperative morbidity, pain, and debility. These benefits are clearest in a patient whose large aneurysm precludes observation, and whose poor health precludes open surgery. The role of endovascular repair is less clear in a patient with a small aneurysm and good health, for whom the benefits depend on long life expectancy, durable protection from risk of rupture, and a low rate of late complications. As endovascular technique and technology have evolved, these factors have changed, and so have attitudes towards the respective roles of surgical and endovascular aneurysm repair [14,15].
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