Indian Journal of Vascular and Endovascular Surgery

: 2020  |  Volume : 7  |  Issue : 3  |  Page : 208--210

Management of an infrarenal aortic aneurysm – A tale of twin cities!

Edwin Stephen 
 Department of Vascular Surgery, Sultan Qaboos University Hospital, Muscat, Oman

Correspondence Address:
Edwin Stephen
Department of Vascular Surgery, Sultan Qaboos University Hospital, Muscat


Guidelines for the management of an abdominal aortic aneurysm vary among vascular surgery societies. The debate between endovascular and open repair for elective repair is still on while an attempt is made to draw a balance between scientific evidence, cost-effective health care, and providing what is best for the patient. As endovascular hardware, software, and skills of the vascular surgeons improve, is the scalpel getting blunt? Will open surgical repair be a forgotten twin in the management of aortic surgery or should a conscious effort be made to preserve this skill? It is time to have guidelines relevant to the Indian subcontinent that encompasses these issues.

How to cite this article:
Stephen E. Management of an infrarenal aortic aneurysm – A tale of twin cities!.Indian J Vasc Endovasc Surg 2020;7:208-210

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Stephen E. Management of an infrarenal aortic aneurysm – A tale of twin cities!. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Sep 29 ];7:208-210
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Several countries in the world have twin cities, for example, London–Westminster; Buda–Pest, and Dallas–Fort Worth. India too has its fair share like the famous – Hyderabad–Secunderabad; Ahmedabad–Gandhinagar; Kochi–Ernakulam; and Kolkata–Howrah, to name a few. Getting around the “old” twin city often requires assistance from one who knows his/her way around, and the history behind its relics often attracts visitors.

Recent literature and guidelines address the use of the “old” open surgical repair (OSR) and “newer” endovascular aortic aneurysm repair (EVAR) in the management of infrarenal aortic aneurysms. Discussion is also raft about the concern that OSR might be a forgotten skill. It is important that vascular surgeons know their way, both management strategies.

 History of Aortic Aneurysm Repair

History of medicine is important to understand the epoch-making thoughts, methods, and techniques that scientists and innovators applied, in order to avoid repeating errors and misunderstandings.[1]

Aortic aneurysms were considered vascular grenades that were invariably lethal, until recent advances in the latter half of the 20th century, which aimed at better outcomes and were definitive, be it open or endovascular repair. The drive seems to have come from experience gained by managing wounds in World War II.[2],[3]

Dr. P. K. Sen and his team from KEM Hospital, Mumbai, have been credited with leading the open aortic surgery revolution in India, in the 1950s.[4] Thereafter, open surgery [Figure 1] saw a speedy growth and is performed successfully in several centers across India and the world. Operative times, morbidity, and mortality saw a significant reduction; however, with the endovascular revolution, the surgical skills of vascular surgeons are arguably at risk of being blunted and exposure of the younger surgeons to open surgery reduced. The Society of Vascular Surgery (SVS) guidelines mention that OSR should be done electively in centers that have an annual volume of ten open aortic operations with a mortality of 5% or less.[5]{Figure 1}

“Balloons are for children” is a saying that was heard when attempts were being made at peripheral angioplasty. Charles Dotter, Thomas Fogarty, and Andreas Gruentzig are credited for starting the endovascular revolution while Prof. Nicolai Leontyevich Volodos (1987) and Dr. Juan C Parodi (1990) for the EVAR revolution.[3],[4],[6],[7]

On October 4, 1997, the India's first EVAR was performed at the Railway Hospital, Chennai, by Prof. Suif Mariano and Prof. Sriram Rajagopal, on a 61-year-old patient with senior vascular surgeons and cardiologists present. The patient, unfortunately, succumbed on October 7, 3 days later. The cause was thought to be the “cheese-cutting effect” of the unprotected stiff guidewire that led to a dissection from the left subclavian artery downward. Thereafter, an EVAR was performed at Mallya Hospital, Bengaluru, by cardiologist Dr. S. S. Ramesh with a Korean surgeon and Dr. K. R. Suresh. This patient succumbed as both renal arteries were covered. In the mid-1998, Dr. K. R. Suresh performed two successful EVARs with a cardiologist, one each in Mallya Hospital and Manipal Hospital, Bengaluru. The first published case of a successful EVAR in India was performed by Prof. George Joseph on February 11, 1999, at the Christian Medical College, Vellore [Figure 2].[8] Later, the same year, Dr. V. S. Bedi performed yet another successful EVAR at The Army Hospital R&R, Delhi. The device used in all the six patients was the Vanguard device™, by Boston Scientific Ltd.{Figure 2}

The endovascular revolution had begun in India and is here to stay.[4],[6],[9] EVARs are performed by vascular surgeons, cardiologists, and interventional radiologists. All of whom have pushed the boundaries of what can be offered endovascularly for complex abdominal aortic aneurysms (AAAs). Innovations, modification of the existing techniques, and cost-effective ways of offering EVAR to the lesser privileged and several platforms to discuss and share complex cases have only aided in pushing the envelope [Figure 3].[10],[11],[12],[13] There are clearly a set of mentors, young consultants, and mentees, who are facile with wire and catheter skills.{Figure 3}

 Open Surgical Repair Versus Endovascular Aortic Aneurysm Repair in Abdominal Aortic Aneurysms

Prof. Roger Greenhalgh[14] published their findings of a 15-year follow-up on patients enrolled in the EVAR-1 trial, which had enrolled 1252 patients from 37 centers in the UK between September 1, 1999, and August 31, 2004. The study concluded that EVAR had an early survival benefit but an inferior late survival compared to OSR. It was suggested that EVAR patients need lifelong surveillance and early reintervention, if needed. The overall mean total and aneurysm-related mortality were, however, not significantly different.

Salata et al.[15] recently presented a population-based cohort study that included 17,683 patients and addressed the question of long-term outcomes of elective EVAR versus OSR for a AAA, with a follow-up of 13.8 years. The mean age was 72.6 years; 80.8% were male; 6100 were of EVAR and 11,583 were of OSR. EVAR had higher survival rate at 1 year and higher major adverse cardiovascular event-free survival rate at 4 years post repair. At a 7-year follow-up, EVAR was associated with higher rate of reintervention. Survival analysis showed no significant difference in long-term survival, reintervention, or secondary rupture between the two managements.

The NICE (2020) and ESVS (2019) guidelines regarding the diagnosis and management were analyzed as there are discordant recommendations. The NICE used a multidisciplinary committee and randomized controlled trials to propose 46 main recommendations. The ESVS used an expert committee with lesser weightage to evidence, leading to 125 recommendations. The NICE recommends OSR for men aged <71 years and for women who present with a rupture, based on the UK-specific economic modeling. The ESVS recommends EVAR based on modern but low quality of evidence.[16]

 Future of Abdominal Aortic Aneurysm Repair

Aortas with aneurysmal disease will dilate over time and newer devices will have to be developed that will incorporate this dilation and prevent leak and migration. EVAR patients should be followed up with ultrasound imaging rather than computed tomography scans, to reduce radiation exposure. Research is on for novel implantable sensor devices that can be used for follow-up.[14]

Patients and treating physicians prefer EVAR,[14],[17] but one must remember that AAAs can rupture and some are better suited for OSR. Open surgery should not be a forgotten city – we need to keep our scalpel sharp. Therefore, a conscious effort must be made to prevent the decline of skills required.[18] Open surgery fellowships seem inevitable, in view of the increased use of endovascular intervention. Would there be an “exo-surgeon” and “endo-surgeon” in vascular teams of the future?

The Vascular Society of India should start a national registry for AAAs[19] and formulate guidelines that are specific to India. These should involve a multidisciplinary team, a preguideline questionnaire, and economic considerations.

Last but not the least, the experience gained from the amazing work done in aortic surgery, be it endovascular or OSR, should be published to enhance learning, create a sense of equilibrium, cause pendular shifts, and showcase the work done in India.[20]


The increase in radiology imaging and master health checkup has led to the increase in incidental finding of an AAA. Patients are better informed about options that are available to them, and it is only right that the treating surgeon/physician knows the current guidelines, is well versed with both EVAR and OSR, and is able to give a balanced opinion as to the best option for the patient. There is a need for a national registry, guidelines, and increase in publication of the experience of AAA management in India. A conscious effort needs to be made to ensure that the art of open aortic surgery is not lost… a forgotten twin city.


I thank Drs. George Joseph, N. Sekar, K. R. Suresh, and V. S. Bedi in helping piece together the history of EVAR in India.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Suresh KR. Footprints on the sands of time. Indian J Vasc Endovasc Surg 2020;7:1-12.
2Cooley DA. A brief history of aortic aneurysm surgery. Aorta (Stamford) 2013;1:1-3.
3Ivancev K, Vogelzang R. A 35 year history of stent grafting, and how EVAR conquered the world. Eur J Vasc Endovasc Surg 2020;59:685-94.
4Verma H, Rai K, Vallabhaneni SR, Tripathi R. History of aortic surgery in India. Indian J Vasc Endovasc Surg 2015;2:105-11.
5Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee AW, Mansour MA, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018;67:2-77.e2.
6Subramanian S. The beginning of endovascular aortic aneurysm repair. Indian J Vasc Endovasc Surg 2018;5:283-5.
7Fogarty TJ, Hermann GD. Endovascular techniques and peripheral vascular surgery. Surg Technol Int 1991;I: 150-4.
8Joseph G, Rajendiran G, Aggarwal S, Korula N. Successful treatment of type I and type III primary endoleaks and a femoral pseudoaneurysm using Passager stent grafts following endoluminal repair of an abdominal aortic aneurysm. Indian Heart J 2000;52:218-20.
9Stephen E. Endovascular therapy in vascular surgery-how relevant is it to India? Curr Med Issues 2020;18:153-5.
10Stephen E, Joseph G, Sen I, Chacko S, Premkumar P, Varghese L, et al. A novel cautery instrument for on-site fenestration of aortic stent-grafts: A feasibility study of 18 patients. J Endovasc Ther 2013;20:638-46.
11Premkumar P, Joseph G, Stephen E, Agarwal S. Surgeon-modified aortic stent grafts in third world countries. Abstract J Vasc Surg 2015;61:124S.
12Joseph G, Premkumar P, Thomson V, Varghese M, Selvaraj D, Sahajanandan R. Externalized guidewires to facilitate fenestrated endograft deployment in the aortic arch. J Endovasc Ther 2016;23:160-71.
13Gopalamurugan AB, Meenakshi MS, Abubacker RM. India's first single side access EVAR device implantation: A hope for patient's with poor vascular access. IHJ Cardiovasc Case Rep 2017;1:92-5. [ 2017.05.006].
14Patel R, Sweeting MJ, Powell JT, Greenhalgh RM; EVAR trial investigators. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): A randomised controlled trial. Lancet 2016;388:2366-74.
15Salata K, Hussain MA, de Mestral C, Greco E, Aljabri BA, Mamdani M, et al. Comparison of outcomes in elective endovascular aortic repair vs. open surgical repair of abdominal aortic aneurysms. JAMA Netw Open 2019;2:e196578.
16Powell JT, Wanhainen A. Analysis of the differences between the ESVS 2019 and NICE 2020 guidelines for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2020;60:7-15.
17Richards T, Jones K, Club R. Future of vascular surgical training: The trainees' views. Ann R Coll Surg Engl 2008;90:96-9.
18Gombert A, Jacobs MJ. Keep your knife sharp-An appeal for more education in open aortic surgery. Eur J Vasc Endovasc Surg 2020;59:766.
19Unnikrishnan M, Savlania A, Goura P, Verma H, Tripathi RK. Aortic diseases in India and their management: An experience from two large centers in South India. Indian J Vasc Endovasc Surg 2016;3:20-3.
20Stephen E. Why, how and where to publish? Indian J Vasc Endovasc Surg 2018;5:139-40.