ENDOVASCULAR ANEURYSM REPAIR (EVAR): POSITION STATEMENT BY THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY (EACTS) AND EUROPEAN SOCIETY FOR CARDIO-VASCULAR SURGERY (ESCVS)

Surgical treatment of the aorta is still one of the most challenging surgical procedures, with substantial surgical mortality and sometimes devastating morbidity. Very often, and especially in case of acute aortic syndromes, the surgical conditions of the aorta are encountered in the aged, polymorbid population, with its inherently higher risk of surgery. The EACTS and ESCVS acknowledge the emerging role and the expanding application of EVAR techniques in the treatment of the aortic disease. Regretfully, there is a paucity of properly designed, prospective randomized trials of thoracic EVAR, which preclude a scientifically based recommendation for the appropriate use of this technique. It is also an evolving technology, with rapid advances in the field of endovascular prostheses and their trans-catheter applications. This statement summarizes the present position of the EACTS and ESCVS in the ongoing controversy about EVAR in the thoracic aorta.

1. Who should be performing EVAR in the aorta? Surgeons with profound surgical experience in the conventional treatment of the aortic disease are best qualified to asses the patients, having a solid knowledge of the anatomy, patophysiology and natural history of the disease, which becomes essential when recommending either treatment modalities (surgery or EVAR) in asymptomatic or oligo-symptomatic patients. They are also the specialists who have to take over the management in the event of complications emerging from EVAR therapy. Obviously, catheter-based technologies require the proper training in this special field, which a surgeon performing EVAR must acquire. Most commonly, the procedure is performed by a dedicated team, consisting of a specially trained surgeon, and invasive radiologist or cardiologist, supported by an operating team and by the technical staff necessary for the use of imagining equipment. Many members of the EACTS and ESCVS are already active in this field, as the recent survey has shown; and they utilize various organizational and technical modalities, tailored to their special local talent and needs.
   
2. Where should the thoracic EVAR be performed? Very often EVAR requires substantial surgical preparation in case of disease of iliac arteries, or in EVAR extending into the aortic arch or into the upper abdominal aorta. Transposition of the arch vessels or preparatory revascularization of the visceral arteries make the use of specially equipped operating suite necessary, with a high-quality imagining equipment available, to permit the precise placements of devices introduced by trans-catheter technique. Therefore, the EVAR is best performed in an operating suite equipped with advanced imagining equipment, high quality angiography unit being the first requirement. The teams performing EVAR are well advised to prepare such operating suites, which also require substantial investment by the hospital authorities.
   
3. What is the adequate training for EVAR? The technology has progressed beyond the pioneering stage, and serious preparatory training is necessary to avoid the beginner?s errors. Surgeons who are entering this field must have both training in the classical methods of open surgical treatment of the thoracic and abdominal aorta and its branches; and a thorough training in the endovascular technology. Attendance of some courses and/or wet lab training is not sufficient: hands-on experience in EVAR, first assisting and later performing the procedure in patients, with a thorough training in related procedures (e.g. control of endoleaks and other complications) is considered obligatory at this stage of EVAR development. In practical sense, this involves a longer training period (several months) in a high-volume institution, with the possibility of performing supervised procedures, exactly as in classical surgical training.
   
4. What is considered an appropriate continuous education in EVAR? The field is rapidly evolving, and surgeons working in the EVAR are advised to invest heavily in their continuous education. Postgraduate courses, special topic-oriented meetings, wet labs, industry based symposia and careful study of the relevant literature is considered essential to keep abreast in the field.
   

In summary, EACTS and ESCVS believe that the EVAR is a valuable tool in the surgical armamentarium, which will further enrich the spectrum of treatment of the aortic disease. Surgeons working in this field are advised to become involved in this technology, and to assume a leading role both in selecting the patients and performing EVAR, together with other specialists.

Marko Turina , MD
For the Endovascular Resources Group of the EACTS and ESCVS