The "scandal" of late mortality after EVAR: a legacy of the past, an urban myth, or an unsolved issue? A clinical and ethical review

Since the introduction of endovascular aortic repair (EVAR) for abdominal aortic aneurysms (aaas) treatment in 1990s, progressive improvements have been achieved in stent-graft technology, and surgeons’ experience has grown considerably. Evidences and guidelines derive from conclusion of randomized clinical trials (rCTs) who report only an initial and partial benefit for EVAR over open repair (OR), suggesting EVAR only for high-compromised patients with suitable anatomy. Some authors believe that evar is not the preferred approach in patients fit for OR and with long life expectancies. Moreover, Brown et al. suggested that EVAR offers a clear 30-day mortality benefit over OR, but this early benefit is not translated into a long-term survival advantage. Nevertheless, EVAR improvements have followed general developments in surgical technique, the advent of endovascular surgery, the centralization of aortic surgery to specialist teams with high operative caseload. Those findings are confirmed by the experience from high volume centers suggesting evar as preferred treatment for AAA patient with both standard and challenging anatomies. The “scandal” of late mortality after evar represents not only a concrete issue in case of litigation, but it proposes important and delicate ethical issues. In daily practice, indeed, the information relating to surgery, whether open or evar, is often judged to be of very poor quality. special procedures for favoring the patient’s understanding of options and outcomes in order to come to a decision have thus been created.