Contemporary abdominal aortic aneurysm devices, three decades of research and development with big data. Why has the best graft not been produced yet? A missed opportunity

Changes are emerging once more in the management of abdominal aortic aneurysm. Following an almost ubiquitous adoption of endovascular techniques, questions are arising regarding long-term outcomes and device durability. This debate has been ignited by the publication of draft guidelines by the National Institute for Health and Care Excellence (NICE) in the UK, which recommend against Endovascular Aortic Repair (EVAR) as first line management of elective infrarenal aortic aneurysm, largely on the grounds of high re-intervention rates and cost-effectiveness. The NICE guidelines have sent major ripples through the community of surgeons and interventionalists who treat these patients, but yet they have also provided an opportunity for reflection and that forms the basis for this review. EVAR and open surgical repair are not competitive therapies, each has its merits and a patient specific approach should be taken when deciding on the appropriate method for each individual patient. Endovascular repair still has a major role to play in modern practice and will continue to do so for years to come, with the caveat that contemporary devices are not perfect and there is room for improvement. In this review a comprehensive overview of the commercially available devices is presented, which includes various clinical, biomechanical and biological considerations.