Endovascular aneurysm repair in the elderly: First do no harm

Endovascular aneurysm repair (EVAR) has become the intervention of choice for supra-threshold aortic aneurysms due to the lower 30-day mortality of EVAR as compared with open surgery, despite no long-term longevity gains. Trials such as EVAR-1 that established the current status of endovascular aortic intervention often excluded participants over the age of 80, and specific studies of EVAR in the elderly reveal higher mortality than accepted averages. Analyses of the cost-effectiveness of EVAR have not demonstrated superiority of endovascular intervention over open repair, in particular when considering complications such as endoleak. Post-intervention surveillance and the frequent need for re-intervention following EVAR has a detrimental impact on quality of life. Taking these factors into consideration, combined with an ageing population and the likely increase in octogenarian endovascular intervention, there is a clear clinical need for appropriate risk-stratification of elderly patients with supra-threshold aneurysms to determine who will benefit from endovascular repair.