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Re: Endovascular versus Conventional Open Repair of Acute Abdominal Aortic Aneurysm: Feasibility and Preliminary Results

We congratulate the authors on their important contribution to the rapidly expanding field of emergency endovascular aneurysm repair. Our experience agrees with their conclusions that endovascular aneurysm repair of symptomatic aortic aneurysms is a feasible technique that shows promising results. However, we would contend their implication that the feasibility of the technique has only just been demonstrated: the first successfully reported case was performed in Nottingham in 1994.2 Neither is the literature on this subject limited. Unfortunately, the authors neglected to mention a number of important publications on the subject over the past 2 years.3–6 Moreover, many of their points of discussion have been debated elsewhere.7 Specifically, the suitability of ruptured aortoiliac aneurysms for endovascular repair has been addressed.8 The Zurich,5 Ulm,4 and Eindhoven6 groups suggested a suitability of 58%, 67% and 81%, respectively, from their prospective intention-to-treat experiences. The authors also mention only one solution to the problem of sizing of endografts in the emergency setting: the Montefiore endograft system. However, others exist and have been described in both our reports3 and those from Eindhoven.6 Many of the newer modular bifurcated designs accommodate a wide variety of aneurysm morphology; in fact, bifurcated endografts were used exclusively by the group from Zurich.5 Finally, we would suggest that endovascular repair of ruptured abdominal aortic aneurysms should be judged almost exclusively on its ability to reduce perioperative mortality, which remains prohibitively high following open repair. Other endpoints, such as cost and quality of life, are much less important indicators of outcome. The authors ask for a randomized controlled trial to answer the questions; such a prospective trial is currently in progress in Nottingham.