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Open AccessPublished:August 27, 2021DOI:https://doi.org/10.1016/j.jvscit.2021.06.001
      We sincerely thank Barillà et al for their letter entitled “When a surgical approach is more favorable” regarding our paper wherein we had reported the case of a patient with bilateral absence of the common iliac artery associated with an infrarenal abdominal aortic aneurysm (AAA). The patient was successfully treated by endovascular aortic aneurysm repair (EVAR) using a technical modification to maintain pelvic perfusion.
      • Pham M.-A.
      • Le T.-P.
      Preservation of internal iliac artery flow during endovascular aortic aneurysm repair in a patient with bilateral absence of common iliac artery.
      First, Barillà et al have raised a query about the rationale of an elective repair in an asymptomatic AAA of 52 mm diameter. Indeed, evidence from four randomized controlled trials (RCTs), summarized in a Cochrane review, has indicated that aneurysms <55 mm in diameter should be managed conservatively.
      • Filardo G.
      • Powell J.T.
      • Martinez M.A.
      • Ballard D.J.
      Surgery for small abdominal aortic aneurysms.
      Despite all this evidence, in several Western countries, AAAs in men are still repaired below the 55 mm threshold.
      • Beck A.W.
      • Sedrakyan A.
      • Mao J.
      • Venermo M.
      • Faizer R.
      • Debus S.
      • et al.
      Variations in abdominal aortic aneurysm care: a report from the International Consortium of Vascular Registries.
      Another study in the USA has shown that more than 40% of repairs were performed on small AAAs <55 cm.
      • Karthikesalingam A.
      • Vidal-Diez A.
      • Holt P.J.
      • Loftus I.M.
      • Schermerhorn M.L.
      • Soden P.A.
      • et al.
      Thresholds for abdominal aortic aneurysm repair in England and the United States.
      Furthermore, three RCTs comparing EVAR and open surgical repair (OSR) for AAA (DREAM, OVER, ACE) enrolled patients with an aneurysm diameter of ≥ 50 mm.
      • Prinssen M.
      • Verhoeven E.L.
      • Buth J.
      • Cuypers P.W.
      • van Sambeek M.R.
      • Balm R.
      • et al.
      A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.
      • Lederle F.A.
      • Freischlag J.A.
      • Kyriakides T.C.
      • Padberg Jr., F.T.
      • Matsumura J.S.
      • Kohler T.R.
      • et al.
      Outcomes following endo-vascular vs open repair of abdominal aortic aneurysm: a randomized trial.
      • Becquemin J.P.
      • Pillet J.C.
      • Lescalie F.
      • Sapoval M.
      • Goueffic Y.
      • Lermusiaux P.
      • et al.
      ACE trialists. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low-to-moderate-risk patients.
      In addition, it is important to note that the mean infrarenal abdominal aortic diameter of the Asian population is much smaller than that of the Caucasian population (14.4-18.7 mm vs 19.3-21.3 mm).
      • Singh K.
      • Jacobsen B.K.
      • Solberg S.
      • Kumar S.
      • Arnesen E.
      The difference between ultrasound and computed tomography (CT) measurements of aortic diameter increases with aortic diameter: analysis of axial images of abdominal aortic and common iliac artery diameter in normal and aneurysmal aortas. The Tromsø Study, 1994–1995.
      • Rogers I.S.
      • Massaro J.M.
      • Truong Q.A.
      • Mahabadi A.A.
      • Kriegel M.F.
      • Fox C.S.
      • et al.
      Distribution, determinants, and normal reference values of thoracic and abdominal aortic diameters by computed tomography (from the Framingham Heart Study).
      • Allison M.A.
      • Kwan K.
      • Di Tomasso D.
      • Wright C.M.
      • Criqui M.H.
      The epidemiology of abdominal aortic diameter.
      • Guo W.
      • Zhang T.
      Abdominal aortic aneurysm prevalence in China: determining specific screening parameters to assess abdominal aortic aneurysms in the Chinese population.
      • Adachi K.
      • Iwasawa T.
      • Ono T.
      Screening for abdominal aortic aneurysms during a basic medical checkup in residents of a Japanese rural community.
      • Oh S.H.
      • Chang S.A.
      • Jang S.Y.
      • Park S.J.
      • Choi J.O.
      • Lee S.C.
      • et al.
      Routine screening for abdominal aortic aneurysm during clinical transthoracic echocardiography in a Korean population.
      • Laughlin G.A.
      • Allison M.A.
      • Jensky N.E.
      • Aboyans V.
      • Wong N.D.
      • Detrano R.
      • et al.
      Abdominal aortic diameter and vascular atherosclerosis: the multi-ethnic study of atherosclerosis.
      In reality, in some Asian countries including ours, an AAA with an aneurysm diameter of ≥ 50 mm is routinely electively repaired.
      Barillà et al have also proposed that in a younger and fitter patient with a long life expectancy, an open repair using a transperitoneal approach with preservation of both internal iliac arteries (IIAs) should have been performed for prevention of potential colonic ischemia and for the best long-term results. In fact, evidence has pointed out an increased rate of complications after 8-10 years with earlier generation stent grafts. Thus, it is reasonable to suggest an OSR first strategy in patients with a long life expectancy of more than 10-15 years.
      • Wanhaineen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      Editor’s Choice—European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
      However, nearly all the evidence suggests a significant short-term survival benefit for EVAR over OSR. Moreover, the recent findings from the OVER trial showed that overall long-term survival was similar between the EVAR group and the OSR group.
      • Lederle F.A.
      • Kyriakides T.C.
      • Stroupe K.T.
      • Freischlag J.A.
      • Padberg Jr., F.T.
      • Matsumura J.S.
      • et al.
      OVER Veterans Affairs Cooperative Study Group
      Open versus endovascular repair of abdominal aortic aneurysm.
      In addition, owing to speedy technological and medical development, the available RCTs comparing OSR and EVAR are partially no longer relevant to the current best practices. As a consequence, despite data from multiple RCTs and meta-analysis, the recommendation that states “In patients with long life expectancy, open abdominal aortic aneurysm repair should be considered as the preferred treatment modality” was recently classified as Class IIa, Evidence B.
      • Wanhaineen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      Editor’s Choice—European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
      Besides, pertaining to an IIA occlusion during EVAR, evidence has revealed that colonic ischemia is very rare and more frequent with bilateral IIA occlusions.
      • Jean-Baptiste E.
      • Brizzi S.
      • Bartoli M.A.
      • Sadaghianloo N.
      • Baqué J.
      • Magnan P.E.
      • et al.
      Pelvic ischemia and quality of life scores after interventional occlusion of the hypogastric artery in patients undergoing endovascular aortic aneurysm repair.
      • Bosanquet D.C.
      • Wilcox C.
      • Whitehurst L.
      • Cox A.
      • Williams I.M.
      • Twine C.P.
      British Society of Endovascular Therapy (BSET)
      Systematic review and meta-analysis of the effect of internal iliac artery exclusion for patients undergoing EVAR.
      • Kouvelos G.N.
      • Katsargyris A.
      • Antoniou G.A.
      • Oikonomou K.
      • Verhoeven E.L.
      Outcome after interruption or preservation of internal iliac artery flow during endovascular repair of abdominal aorto-iliac aneurysms.
      In the present patient, because of the morphological variation, preservation of both IIAs during EVAR was considered to be a high-risk procedure. Therefore, unilateral IIA occlusion was performed with a plug at the proximal part of the right IIA, minimizing the potential risk of a pelvic ischemia.
      • Bosanquet D.C.
      • Wilcox C.
      • Whitehurst L.
      • Cox A.
      • Williams I.M.
      • Twine C.P.
      British Society of Endovascular Therapy (BSET)
      Systematic review and meta-analysis of the effect of internal iliac artery exclusion for patients undergoing EVAR.
      In conclusion, the patient in question was suitable for both EVAR and OSR. Before making the final choice, the patient was informed of the advantages and disadvantages of the various treatment options. Therefore, although we agree with the authors that EVAR may theoretically be more complex than OSR in this vascular anomaly, we believe that some level of liberty for individualized decision-making should be accepted, in respecting the patient's preferences to a certain extent.

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