The current size threshold for elective abdominal aortic aneurysm (AAA) repair is
5.5 cm. Over this diameter limit, the AAA rupture rate exceeds the perioperative
mortality of open surgical repair. Endovascular aneurysm repair (EVAR) is
associated with lower perioperative mortality rates, so it seems logical to
hypothesize that the size threshold for endovascular AAA repair should be
lowered. The arguments supporting this proposal are: (1) the EVAR-associated
mortality rises several fold with increasing age, (2) larger AAAs have more
complex anatomy that may not be suitable for EVAR, and (3) smaller AAAs treated
with EVAR have lower perioperative and long-term mortality and fewer secondary
interventions. Future guidelines may need to consider lowering the size
threshold for elective AAA repair in the endovascular era in certain patient
subgroups. The reduction of the size threshold should be counterbalanced against
the cost of the procedures, as well as the age, life expectancy, and general
condition of the patient.
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