Endovascular treatment (EVAR) in patients with abdominal aortic aneurysms and synchronous neoplasms

The association between abdominal aortic aneurysms (AAA) and cancer is becoming more and more frequent, giving rise to several questions regarding the therapeutic and surgical management strategies for both diseases. Endovascular aneurysm repair (EVAR) is the treatment of choice for complex and high-risk patients. In this study we reviewed our experience with patients concomitantly affected by any type of cancer and AAA treated by EVAR at our institution over the last six years. From April 2001 to July 2007, 497 AAA patients underwent open or endografting repair in the 1st Division of General Surgery--Service of Vascular Surgery of the University of Verona. In 53 cases (10.6%) an association with a solid neoplasm was found and 27 of these patients (50.9%) were treated by EVAR. Twenty patients underwent a two-stage approach, with EVAR performed first, while in 5 cases a one-stage approach was preferred on the basis of the general condition of the patients, the site of the tumour to be resected, the logistic possibilities and increased experience of the operators with EVAR. Two patients received chemotherapy after EVAR. There was no in-hospital mortality and four perioperative complications (14.8%) were registered. During a mean follow-up of 25.7 months (range: 2-64 months) 5 deaths occurred, 2 in the short term and 3 in the long term, none of which were related to AAA treatment. Three type-2 endoleaks occurred that sealed spontaneously and 62.9% of the treated aneurysms had a mean 20% decrease in diameter while the others presented no variations. In our experience, EVAR was a safe and effective treatment of AAA patients with concomitant malignancies with a relatively low procedure-related morbidity and no mortality. A simultaneous surgical approach can be achieved safely, performing EVAR as the first step without significant risks. Simultaneous treatment has the advantage of avoiding a second major procedure and eliminates the risk of aortic aneurysm rupture in the postoperative period or during chemotherapy in patients who are usually in poor general condition. Care must be taken with regard to the choice of the device to be used and the possible vascular complications of the visceral circulation. In our opinion, EVAR should be considered the treatment of choice in these patients, taking into account, however, that this treatment is not always feasible in all cases and that in patients with a normal life-expectancy (tumour-cured) it may not always be the right choice. Thus, a multidisciplinary approach is necessary in the individual evaluation of these challenging patients in order to make the right decisions.