EVAR, TEVAR, FEVAR, too far?

Endovascular aneurysm repair (EVAR) is the greatest technological advance in the field of vascular and endovascular surgery in the past 15 years. However, its widespread application has created potential problems, and EVAR may be overused in some circumstances. As long-term outcome data are being sought for EVAR, it is becoming apparent that complications (infection, device migration, and the development of late endoleaks, aneurysm growth, and rupture) are occurring at a higher rate than anticipated. It is also apparent that follow-up is not complete in a large proportion of patients after EVAR, and these are the patients most prone to present with late complications. Surgeons are placing devices in large numbers of patients with poor anatomy for EVAR, in part because of pressures from patients, families, and referring physicians. In patients with good anatomy, EVAR is an excellent option and will likely be durable. In those with unfavorable anatomical features, we need to better appreciate the potential for adverse long-term outcomes and advocate more strongly for open repair.