Identification of abdominal aortic aneurysm patients with different clinical features and clinical outcomes

To determine the clinical characteristics and factors influencing outcome in patients with atherosclerotic abdominal aortic aneurysms (AAA), 526 patients who underwent aneurysmal resection were retrospectively reviewed: Group I had clinical evidence of atherosclerotic occlusive disease; Group II had no evidence of atherosclerotic occlusive disease. The incidence of ruptured AAA, multiple aneurysms, and a family history of AAA was higher in Group II patients. We concluded that patients with AAA and without atherosclerotic occlusive disease in other areas represent a subgroup with peculiar clinical characteristics. In planning operative treatment and during the follow-up period, it should be kept in mind that Group II patients have a higher incidence of aneurysm rupture; the incidence of late pseudoaneurysm is higher; and there is a greater possibility of aneurysm in other arterial segments. It remains to be seen if the pathogenetic mechanism of AAA formation in Group II patients is different from that in Group I patients.     

Inflammatory aneurysms of the abdominal aorta: incidence, pathologic, and etiologic considerations

Among 486 patients undergoing repair for abdominal aortic aneurysm (AAA) during a 12-year period, 30 (6.2%) had evidence of "inflammatory" AAA. One patient (3%) had acute rupture, and six patients (20%) had chronic contained rupture. Ureteral obstruction was evident in 20% of the patients. In the early period of the study there were two postoperative deaths and operative time and blood loss were significantly increased. In the last period of the study, no attempt was made to separate the duodenum and the ureters from the aneurysm; there was no operative mortality, and operative time and blood loss were similar to that of patients with atherosclerotic aneurysms. In 23 of 100 specimens of atherosclerotic AAA, microscopic findings resembling inflammatory AAA were found. On the basis of our study we conclude the following: (1) Inflammatory AAAs are simply atherosclerotic aneurysms that show an unusual accentuation of the chronic inflammation observed in relation to atherosclerotic aneurysms. (2) Operative technique should be modified to avoid excessive dissection and lysis of ureters and duodenum. (3) Excellent early and late results can be expected with proper surgical technique. (4) The causes of AAA are multiple, and chronic contained rupture of the aneurysm and reactive lymphatic hyperplasia might play a role of greater significance than previously thought.     

Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients

Graft inclusion and vessel reattachment to openings made in the graft were employed in the treatment of 605 patients with thoracoabdominal aortic aneurysms. These patients were divided into four groups on the basis of the extent of aneurysm. Group I consisted of those patients with involvement of most of the descending thoracic and upper abdominal aorta; group II involved most of the descending thoracic aorta and most or all of the abdominal aorta; group III involved the distal descending thoracic aorta and varying segments of abdominal aorta; and group IV involved most or all of the abdominal aorta including the segment from which the visceral vessels arose. The cause of aneurysm formation was medial degenerative disease in 80%, and dissection in 17%; other causes were responsible in the remaining 3%. The median age was 65 years and associated diseases including aneurysms involving other segments, atherosclerotic occlusive disease, heart disease, chronic obstructive pulmonary disease (COPD), hypertension, and renal insufficiency were frequent. The aneurysm was symptomatic in 70% of cases and rupture had occurred in 4% of cases. There were 54 (8.9%) early (30-day) deaths and 151 late deaths; 400 (66%) patients were still alive 3 months to 20 years after operation, including 60% at 5 years. Statistically significant pre- and intraoperative variables by univariate analysis that were predictive of increased risk of early death were advancing age, associated diseases that included COPD, renal artery occlusive disease, atherosclerotic heart disease, renal insufficiency, and long aortic clamp time. Three of these (age, clamp time, and the presence of COPD) retained significance by multivariate analysis. Variables predictive of risk of late death were age, dissection, extent of aneurysm, rupture, heart disease, cerebrovascular disease, COPD, hypertension, and poor renal function. Age, rupture, renal dysfunction, extent of aneurysm, and dissection retained their significance by multivariate analysis. Variables predictive of neurologic disturbances of the lower extremities included rupture, reattachment of intercostal and lumbar arteries, clamp time, dissection, extent and age. Rupture, reattachment of vessels, dissection, and extent of aneurysm retained significance by multivariate analysis. Thus, the risk of this complication was greatest in patients with extensive lesions (group II) with aortic dissection. The greatest risk of renal failure after operation that required dialysis was in patients who had impaired renal function before operation. Methods employed did not prevent these complications.     

True juxta-anastomotic aneurysms in the residual infra-renal abdominal aorta.

INTRODUCTION: abdominal aortic dilatation can occur above the graft following repair of infra-renal abdominal aortic aneurysm (AAA). This study aimed to determine the incidence and possible aetiological associations of recurrent juxta-anastomotic aneurysms following open repair of AAA. METHODS: the diameter of the infra-renal aorta above the graft of 135 patients who had previously undergone open AAA repair was determined using ultrasound. In those where the diameter was greater than 40 mm a CT scan was undertaken. Co-morbid and operative details were determined from the patients and their clinical notes. RESULTS: seven patients had true juxta-anastomotic aneurysms (>40 mm) in the residual infra-renal abdominal aorta, the occurrence of which was associated with tobacco smoking and hypertension. There was no association with other co-morbid factors, surgical operative details or the development of iliac aneurysms (which occurred in 3% of patients). CONCLUSIONS: true juxta-anastomotic aneurysms develop in the residual infra-renal neck of patients following open repair of abdominal aortic aneurysm. Tobacco smoking and hypertension are significant factors associated with the development of these aneurysms. This group of patients may warrant surveillance to prevent aneurysm rupture.     

Case report of a hybrid endovascular approach to an abdominal aortic dissection with retrograde thoracic extension and infrarenal aneurysm

Spontaneous abdominal aortic dissection (AAD) with retrograde thoracic extension is an extremely rare occurrence with a high mortality. Abdominal aortic dissection can be associated with an abdominal aortic aneurysm (AAA) and the presence of an AAD with an AAA mandates surgical intervention because of a high rate of rupture. We present the case of a 53-year-old woman with a spontaneous AAD that extended retrograde into the thoracic aorta with a concomitant supraceliac intimal tear and an infrarenal AAA repaired electively with a hybrid approach using a supraceliac stent graft and an open infrarenal aortobiiliac graft. This hybrid approach provided an excellent outcome of this rare and complex vascular pathology.     

大动脉病变的外科手术治疗

目的　探讨大动脉病变的手术治疗方法。方法　回顾性分析 86例大动脉病变外科手术治疗的临床资料。其中胸腹主动脉瘤 3例 ;降主动脉夹层破裂并巨大假性动脉瘤形成椎骨破损 2例 ;腹主动脉局限性夹层破裂并假性动脉瘤形成 2例 ;腹主动脉瘤十二指肠空肠曲瘘并消化道大出血 1例 ;腹主动脉瘤破裂并休克 5例 ,腹主动脉外伤后破裂 3例 ;腹主动脉瘤和 /或并单或双侧髂动脉瘤2 1例 ;髂动脉瘤 6例 ;股动脉瘤 9例 ;髂或股动脉假性动脉瘤 2 1例 ;右锁骨下动脉和椎动脉起始部破裂并巨大假性动脉瘤形成 1例 ;左或右锁骨下动脉破裂并假性动脉瘤形成 3例 ;颈动脉瘤 2例 ,颈动脉假性动脉瘤 7例。行人工血管置换治疗 71例 ,自体静脉修补 3例 ,动脉破口修补术 12例。结果　术中及术后 3 0d死亡率为 3 .5 % ( 3 /86)。随访 73例 ,随访时间 1个月至 5年 ,除 1例腹主动脉瘤十二指肠瘘患者已死亡外 ,余均生存良好。结论　大动脉病变的外科手术治疗仍然是一种十分有效和经济实用的方法 ,在技巧等方面的改进有利于提高手术的成功率     

Simultaneous endovascular exclusion of thoracic aortic aneurysm with open abdominal aortic aneurysm repair.

BACKGROUND: The treatment of aneurysms at multiple sites within the aorta is problematic. METHODS: Between March 2002 and June 2003 in the Department of General, Vascular and Transplant Surgery, Medical University of Warsaw six patients with coexisting abdominal and descending thoracic aortic aneurysms underwent simultaneous open abdominal aortic aneurysm (AAA) repair and endoluminal thoracic aortic aneurysm (TAA) repair. The indication for a combined procedure was a diagnosed descending TAA and AAA with no significant risk factors for open aortic surgery or technical contraindications for endovascular treatment of TAA. RESULTS: One patient died in the peri-operative period while the other five patients all recovered well after surgery and were discharged with both aneurysms excluded. CONCLUSION: Endovascular treatment of TAA combined with a simultaneous open AAA repair is an efficient and relatively safe treatment modality in patients with TAA and AAA disqualified from endovascular repair. The fact that thoracotomy is not a necessity significantly lowers the complication rate in these patients.     

Inflammatory abdominal aortic aneurysms: a thirty-year review

The operative records of 2816 patients undergoing repair for abdominal aortic aneurysm (AAA) from 1955 to 1985 were reviewed. Inflammatory aortic or iliac aneurysms were present in 127 patients (4.5%), 123 men and four women. Most patients were heavy smokers (92.1%). Clinical evidence of peripheral arterial occlusive disease and coronary artery disease was found in 26.6% and 39.4%, respectively. Additional aneurysms occurred in half of the patients; iliac aneurysms were the most common (55 patients), followed by thoracic or thoracoabdominal (17 patients), femoral (16 patients), and popliteal aneurysms (10 patients). Ultrasound and computed tomography suggested the diagnosis in 13.5% and 50%, respectively; angiography was not helpful. Excretory urographic findings of medial ureteral displacement or obstruction suggested the diagnosis in 31.4%. The aneurysm was repaired in 126 patients. Only one patient experienced acute aneurysm rupture, but eight patients had chronic contained leakage. When compared with patients who have ordinary atherosclerotic aneurysms, patients with inflammatory aneurysms are significantly more likely to have an elevated erythrocyte sedimentation rate (ESR, 73% vs. 33%, p less than 0.0001); weight loss (20.5% vs. 10%, p less than 0.05); symptoms (66% vs. 20%, p less than 0.0001); and an increased operative mortality rate (7.9% vs. 2.4%, p less than 0.002). The triad of chronic abdominal pain, weight loss, and elevated ESR in a patient with an abdominal aortic aneurysm is highly suggestive of an inflammatory aneurysm and may be beneficial in the preoperative preparation of the patient for aneurysm repair.     

Selective use of a right retroperitoneal approach to abdominal aortic aneurysm.

The repair of infrarenal abdominal aortic aneurysm by right retroperitoneal dissection using a standard midline transperitoneal incision has previously been described but its clinical application has not been evaluated. Over a 14-year period 144 elective abdominal aortic aneurysm grafts were performed by a single surgical firm. Of these, 11 were carried out by a right retroperitoneal exposure (seven men and four women, aged 63-81 (median 70) years). The indications were to improve access for large juxtarenal aneurysms (n = 6) and because of dense abdominal adhesions (n = 3), horseshoe kidney (n = 1) and retroperitoneal fibrosis (n = 1). In each instance, good proximal control of the aorta was achieved. There were no major operative or postoperative complications and all patients were discharged from hospital (median stay 15 days). Follow-up (median 29 months) has revealed no procedure-related complications.     

胸主动脉夹层合并腹主夹层动脉瘤的一期腔内治疗

目的：探讨胸主动脉夹层动脉瘤合并腹主动脉夹层动脉瘤病人一期腔内隔绝术治疗的可行性、手术操作技巧及并发症防治原则。方法和结果：1例Stanford B型胸主动脉夹层动脉瘤合并腹主动脉夹层动脉瘤及双侧髂动脉瘤的病人于2006年3月在本中心接受了腔内隔绝术。MRA检查提示．主动脉弓降交界处开始出现夹层．真腔受压变窄,以胸腹交界处及腹主动脉中段最明显,最扁窄处为0．5cm;假腔在腹主动脉中段明显,最大径约5．0cm,假腔再人口位于左髂总动脉近端。双侧髂总动脉迂曲并呈瘤样扩张。腹腔干、肠系膜上动脉及双侧肾动脉均发自真腔。手术在全麻下进行：降主动脉植入规格为34-34-100mm的直管型Talent移植物,封闭夹层裂口：腹主动脉植入规格为AOI26-12-170mm Talent移植物,远端连接12．12．68mmTalent移植物至一侧髂外动脉,行双侧股-股转流。瘤体隔绝完全,手术约耗时300min,失血1000ml,透视6min,使用威视派克450ml。术后21d出院。术后随访半年,病人生活质量良好,复查CTA显示：移植物通畅,瘤腔内均完全形成血栓。结论：腔内隔绝术的微创特点使一期治疗Stanford B型主动脉夹层动脉瘤合并腹主动脉瘤成为一种比较安全的手术。主动脉长段隔绝也有利于降低截瘫的发生率。     

Early and mid-term results of endovascular stent grafting for aortic aneurysms]

Early and mid-term clinical results of 28 cases of endovascular stent grafting for descending thoracic aortic aneurysms and 11 cases of abdominal aortic aneurysms are reported. Early clinical results: Among 28 patients (7 true thoracic aortic aneurysms, 3 pseudothoracic aortic aneurysms and 8 acute, 4 subacute, and 6 chronic aortic dissections), two patients (7.1%) with ruptured acute aortic dissection or ruptured infected pseudoaneurysm died in the perioperative period. Two of the remaining 26 patients experienced minor complications. Aneurysmal sacs or false lumens at the descending thoracic aorta were completely thrombosed in the 26 patients. One patient (9.1%) with a ruptured abdominal aneurysm died, and one of the remaining 10 patients had renal and peripheral emboli and peripheral vascular trauma. Inadvertent covering of the renal arteries occurred in another patient. Unless one patient had persistent endoleak, aneurysmal sacs in the 10 surviving patients were thrombosed. Mid-term clinical results: One aortic dissection at a different section of the descending aorta occurred 6 months after stent grafting for aortic dissection, and one patient died of pneumonia 3 months after stent grafting for an abdominal aortic aneurysm. CT scanning 6 months after stent grafting revealed a decrease in maximal aneurysmal size in 3 of 9 patients with true or pseudothoracic aneurysms and in 2 of 5 patients with abdominal aortic aneurysms. Five of 9 patients with stent grafting for acute or subacute dissection showed elimination of the false lumen in the descending thoracic aorta in a CT scan 6 months after grafting. One patient with a true thoracic aneurysm and one patient with an abdominal aortic aneurysm showed an increase in aneurysmal size in a CT scan 2 years and one year after treatment, respectively.     

Endovascular Repair of a ruptured abdominal aortic and iliac artery aneurysm with an acute iliocaval fistula secondary to lymphoma

Abdominal aortic aneurysms (AAA) are common and generally asymptomatic unless rupture occurs. A 3 to 4-cm AAA has a 1-2% risk of rupture over 5 years. We present the case of an 85-year-old male with a history of chronic lymphocytic leukemia, a 3-cm infrarenal AAA, and a 2-cm right common iliac artery aneurysm whose AAA ruptured and who developed an acute iliac artery–to–vena cava fistula secondary to eroding adenopathy from an aggressive low-grade lymphoma. Initially, an open repair was attempted but access to the aorta was not possible because of complete encasement of the infrarenal and suprarenal aorta with tumor that was clinically invading the aortic wall. Secondary tumor invasion into the aorta is a rare complication. An endovascular repair was accomplished with successful exclusion of both the aneurysm and the iliocaval fistula. Endovascular repair provides a valuable alternative in the "hostile abdomen" when standard open repair may be hazardous or impossible.     

主动脉病变的手术治疗与腔内血管外科治疗

目的 探讨主动脉病变的手术治疗和腔内血管外科治疗方法。方法 回顾性分析45例胸腹主动脉病变外科治疗的临床资料。结果 男37例，女8例。年龄2l～85(平均年龄64、7)岁。其中胸主动脉夹层ll例；降主动脉夹层破裂并假性动脉瘤形成伴椎骨破损2例；肾上，下型腹主动脉瘤各为3，23例；腹主动脉瘤破裂2例；腹主动脉瘤空肠瘘l例；腹主动脉外伤性破裂3例。45例患者中腔内治疗者l8例，25例行人工血管置换治疗，3例行腹主动脉修补。围手术期死亡率为6．7％(3／45)。随访36例，随访时间2个月～4年，均生存良好。结论 腔内血管外科治疗有着创伤小，术后恢复快，并发症少等优点，有条件行支架型人工血管腔内治疗的可优先考虑腔内治疗。传统手术方法在技巧等方面的改进有利于提高手术的成功率，并能为不具备腔内治疗条件的患者解除疾苦。     

Simultaneous Operations for Combined Thoracic and Abdominal Aortic Aneurysms

Purpose. To assess whether simultaneous operations are appropriate for combined thoracic and abdominal aortic aneurysms.Methods. Simultaneous operations were performed for combined thoracic and abdominal aortic aneurysms in nine patients. The thoracic aortic aneurysm (TAA) was repaired first, followed by repair of the abdominal aortic aneurysm (AAA). Selective cerebral perfusion was used in eight patients, after the exception of one who underwent replacement of the ascending aorta under hypothermic circulatory arrest. The abdominal organs were perfused during distal anastomosis in surgery for Stanford type A aortic dissection or aortic arch aneurysm; via the femoral artery with an aortic balloon occlusion catheter in one patient, and via an occlusion catheter with a perfusion lumen in two patients.Results. All patients underwent planned simultaneous repair of the AAA. One of the patients who underwent simultaneous replacement of both the descending thoracic and abdominal aorta was left with paraplegia, and one patient died suddenly of massive hemoptysis and melena on the 29th postoperative day. Autopsy revealed that the bleeding had been caused by aorto-broncho-esophageal fistulae. The overall operative mortality was 11%.Conclusions. Simultaneous repair of combined TAA and AAA can be safely performed; however, the risk of paraplegia should be considered, especially with simultaneous repair of concomitant aneurysms of the descending thoracic and abdominal aorta.     

Abdominal aortic endograft proximal collapse resulting in aortic aneurysm rupture

An 82-year-old man was transferred to our emergency department due to acute abdominal pain. He had undergone an endovascular abdominal aortic aneurysm repair (EVAR) six years ago. An intravenous contrast-enhanced abdominal computed tomography revealed the rupture of the abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. A Talent (Medtronic, Santa Rosa, CA, USA) modular bifurcated endoprosthesis had vertically collapsed approximately 7 cm after losing its infrarenal fixation. As a result, it led to the repressurization of the aneurysm sac and rupture. The patient was successfully treated by placing three Talent (Medtronic) aortic cuffs. To our knowledge, this is the first reported case of endograft collapse that has manifested with aortic aneurysm rupture. Although they are gradually declining, considerable rates of complications create the 'Achilles' heel' of endovascular repair of AAAs. A lifelong follow-up strategy for patients treated for AAA with EVAR is essential for the early detection and treatment of complications of the procedure.     

Rupture of abdominal aortic aneurysms: A concurrent comparison of outcome of those occurring after endoluminal repair versus those occurring de novo.

AIM: to compare the outcome of patients whose abdominal aortic aneurysm (AAA) ruptured following endoluminal repair with those whose AAA ruptured prior to treatment. PATIENTS: over a 4-year period 434 patients underwent treatment for AAA with conventional open (n=253) and endoluminal repair (n=181). Of those having open repair, 216 patients had elective operations while 41 had operations for ruptured AAA. Four patients with ruptured AAA had undergone endoluminal repair previously (Group I) while the remaining 37 patients ruptured de novo (Group II). The patients in both groups were similar in age and sex but differed clinically. All four patients in Group I had major medical co-morbidities versus 56% in Group II (p<0.05). All patients in group I had a known endoleak following endoluminal repair. All patients underwent open repair. RESULTS: the proportion of patients presenting with hypotension in Group I (1/4) was significantly less than in Group II (30/37). The difference in 30-day mortality for Group I (0%) compared with that for Group II (43%) was significant. The four patients in Group I remain alive and well at follow-up 22 months after operation. The outcome for Group I was better than Group II despite the higher incidence of medical co-morbidities. CONCLUSION: endoluminal AAA repair complicated by a persistent endoleak does not protect from rupture, which may not be accompanied by such major haemodynamic changes and high mortality as rupture de novo. Further long-term results in more patients are required to confirm this intermediate level of protection.     

Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion--Case reports

While the mortality rate for elective abdominal aortic aneurysm (AAA) repair has declined over the last several decades, the rate for ruptured abdominal aortic aneurysm (RAAA) has unfortunately remained disturbingly high. Undiagnosed aneurysms may present with little warning until abdominal pain, syncope, and hypotension signify rupture. Fifty percent of patients with ruptured aneurysms die before reaching a medical facility, and their survival is highly dependent on hemodynamic stability at presentation. The degree of rupture containment and comorbid status of the patient determine hemodynamic stability. Endovascular stent grafting has significantly improved perioperative morbidity and mortality rates for elective AAA repair, and some of the same endovascular techniques can be used to obtain proximal control in patients presenting with RAAA. We describe 3 consecutive cases of RAAA where proximal control was obtained using a percutaneously placed, transfemoral aortic occlusion balloon before induction of anesthesia.     

Combined thoracic aortic dissection and abdominal aortic fusiform aneurysm.

Certain clinical and autopsy findings are described in 13 patients who had both aortic dissection (AD) and fusiform abdominal aortic aneurysm (AAA). All 13 patients had severe and extensive aortic atherosclerosis. The AAA was diagnosed clinically in 9 patients, and 5 had the AAA resected. The AD was diagnosed clinically in 5 patients, and 2 underwent attempted operative repair. Two patients who had the AAA resected because of suspected rupture were found later to have ruptured a more proximal AD. Thus, AD occurs occasionally in patients who have AAA. In older persons with suspected rupture of an AAA, a more proximal rupture of an AD should be ruled out. When both AAA and AD are present in the same patient, the AD is more likely the cause of cardiovascular collapse than is rupture of the AAA.     

Surgical treatment for a ruptured thoracic aortic aneurysm

OBJECTIVE: The treatment for a ruptured thoracic aortic aneurysm remains controversial. This study was undertaken to assess the outcome from surgery. METHODS: Between 1993 and 1998, we have performed 19 operations for a ruptured thoracic aortic aneurysm. Patients with an impending rupture or a chronic false aneurysm were excluded. There were 11 men and 8 women, with a mean age of 70.5 +/- 6.7 years. The aneurysm was caused by dissection in 8 patients. Of these, 7 were acute (Stanford type A, 6; type B, 1), and the other one was chronic (type B). Aortic rupture occurred into the pericardial cavity (n = 7), into the left lung (n = 6), the mediastinum (n = 3), the pleural cavity (n = 2), or into the esophagus (n = 1). Severely unstable hemodynamics were noted in 12 patients with a rupture into the pericardium, mediastinum, or pleural cavity (Group A). Inotropic support was required in each of these patients. Metabolic acidosis developed all but 1 patient. The 7 patients with a rupture into the lung or esophagus coughed or vomited blood (Group B). The operative approach was anterior (n = 17) or lateral (n = 2). Grafts were placed in the ascending aorta (n = 4), ascending and transverse arch aorta (n = 7), transverse arch aorta (n = 3), or in the descending thoracic aorta (n = 5). Selective cerebral perfusion was used in 13 patients. RESULTS: There were 5 hospital deaths (26.3%). The postoperative complications included central nervous system dysfunction (n = 3), low cardiac output syndrome or cardiac arrhythmias (n = 3), respiratory failure (n = 4), acute renal failure (n = 1), and local or systemic infections (n = 4). The perioperative event-free rate was 36.8% overall, 25% in Group A, and 57.1% in Group B. CONCLUSIONS: Patients with unstable hemodynamics require prompt operative intervention. Rupture into the esophagus is associated with a high mortality rate. Rupture in a thoracic aortic aneurysm can be successfully treated with emergency surgery.     

Endovascular repair of abdominal aortic aneurysm in the multifocal atherosclerotic patient

One of the major problems of treating aortic aneurysms has been the multifocal nature of atherosclerotic disease. Co-existing cardiovascular disease in the majority of patients together with chronic obstructive airways disease, renal impairment and hostile abdomen in some, has resulted in 1/3 of patients presenting with aortic aneurysms being regarded as high risk and unfit for open repair. Endovascular repair of aortic aneurysm therefore has much to recommend it since it avoids the need for laparatomy, cross clamping of the aorta and the obligatory blood loss associated with opening of the sac. Between May 1992 and March 2003 we have used the endovascular method to repair abdominal aortic aneurysms (AAA) in 583 patients. Successful repair was achieved in 563 patients (96%). The remaining 20 patients required primary conversion to open repair at the original operation. The 30-day perioperative mortality rate was 13 of 583 (2.2%). In this paper we summarise a number of studies that we have undertaken, comparing endovascular with alternative treatment methods and comparing various types of endovascular prostheses. In addition we report the long-term outcome of endovascular AAA repair as it relates to morphological changes in the proximal neck out to 9 years from operation. We conclude that despite the continuing small incidence of device failure, endovascular is the preferred method of AAA repair in the multifocal atherosclerotic patient. This view is based on the low perioperative mortality, superior survival compared with open repair and our experience of long-term stability in the proximal neck in the majority of patients.