Patient Selection for Endovascular Abdominal Aortic Aneurysm Repair

When endovascular abdominal aortic aneurysm (AAA) repair was first introduced, patients were mainly selected on the basis of their general health status and the length of the proximal aortic neck.1 Because of the experimental nature of the procedure, it was reserved for patients with high cardiopulmonary risk for conventional repair or for patients with an inoperable abdomen. Soon, more pitfalls in patient selection became apparent. Initially, a distal attachment was not considered necessary, as evident from an early drawing of one of Juan Parodi's pioneer publications.' Also thrombus in the proximal neck was found to prevent an adequate proximal seal. In the early experiments, standard polytetrafluoroethylene (PTFE) or polyester tubes were implanted with endovascular stents for graft fixation. Only a small minority of AAA patients (about 10-15%) appeared to meet the strict anatomic inclusion criteria of these tube grafts. Some authors have taken a more liberal approach to the proximal neck, but an unacceptably high rate of proximal attachment system failure was the result.2'3 In addition, the profile and rigidity of these rudimentary introducer systems did not allow endograft placement through tortuous and calcified iliofemoral arteries. With the availability of bifurcated grafts, monoiliac devices, and extension cuffs and with a continuing decrease of the introducer size and rigidity, the suitability rate has now gone up