Reply

We sincerely thank Barillà et al for their letter entitled “When a surgical approach is more favorable” regarding our paper wherein we had reported the case of a patient with bilateral absence of the common iliac artery associated with an infrarenal abdominal aortic aneurysm (AAA). The patient was successfully treated by endovascular aortic aneurysm repair (EVAR) using a technical modification to maintain pelvic perfusion.¹

First, Barillà et al have raised a query about the rationale of an elective repair in an asymptomatic AAA of 52 mm diameter. Indeed, evidence from four randomized controlled trials (RCTs), summarized in a Cochrane review, has indicated that aneurysms <55 mm in diameter should be managed conservatively.²

Despite all this evidence, in several Western countries, AAAs in men are still repaired below the 55 mm threshold.³ Another study in the USA has shown that more than 40% of repairs were performed on small AAAs <55 cm.⁴ Furthermore, three RCTs comparing EVAR and open surgical repair (OSR) for AAA (DREAM, OVER, ACE) enrolled patients with an aneurysm diameter of ≥ 50 mm.5, 6, 7 In addition, it is important to note that the mean infrarenal abdominal aortic diameter of the Asian population is much smaller than that of the Caucasian population (14.4-18.7 mm vs 19.3-21.3 mm).8, 9, 10, 11, 12, 13, 14 In reality, in some Asian countries including ours, an AAA with an aneurysm diameter of ≥ 50 mm is routinely electively repaired.

Barillà et al have also proposed that in a younger and fitter patient with a long life expectancy, an open repair using a transperitoneal approach with preservation of both internal iliac arteries (IIAs) should have been performed for prevention of potential colonic ischemia and for the best long-term results. In fact, evidence has pointed out an increased rate of complications after 8-10 years with earlier generation stent grafts. Thus, it is reasonable to suggest an OSR first strategy in patients with a long life expectancy of more than 10-15 years.¹⁵

However, nearly all the evidence suggests a significant short-term survival benefit for EVAR over OSR. Moreover, the recent findings from the OVER trial showed that overall long-term survival was similar between the EVAR group and the OSR group.¹⁶ In addition, owing to speedy technological and medical development, the available RCTs comparing OSR and EVAR are partially no longer relevant to the current best practices. As a consequence, despite data from multiple RCTs and meta-analysis, the recommendation that states “In patients with long life expectancy, open abdominal aortic aneurysm repair should be considered as the preferred treatment modality” was recently classified as Class IIa, Evidence B.¹⁵

Besides, pertaining to an IIA occlusion during EVAR, evidence has revealed that colonic ischemia is very rare and more frequent with bilateral IIA occlusions.17, 18, 19 In the present patient, because of the morphological variation, preservation of both IIAs during EVAR was considered to be a high-risk procedure. Therefore, unilateral IIA occlusion was performed with a plug at the proximal part of the right IIA, minimizing the potential risk of a pelvic ischemia.¹⁸

In conclusion, the patient in question was suitable for both EVAR and OSR. Before making the final choice, the patient was informed of the advantages and disadvantages of the various treatment options. Therefore, although we agree with the authors that EVAR may theoretically be more complex than OSR in this vascular anomaly, we believe that some level of liberty for individualized decision-making should be accepted, in respecting the patient's preferences to a certain extent.