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Eur J Cardiothorac Surg 2007;31:412-413. doi:10.1016/j.ejcts.2007.01.010
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Internal Medicine and Vascular Medicine Department, Hôpital Cantonal Fribourg, 1700 Fribourg, Switzerland
* Corresponding author. Tel.: +41 26 4267254; fax: +41 26 4267251. (Email: hayozd{at}hopcantfr.ch).
Endovascular repair of aortic aneurysms is becoming an interesting alternative to open surgery in a subset of patients (elderly with several co-morbidities). Ongoing trials are underway in order to obtain head to head comparison of the performance of both methods. Recent reports (EVAR 1–2 and DREAM) have produced results that tend to demonstrate better mortality rate in the early phase (30 days) with a progressive loss of the benefit with time (after 2 years) [1,2]. The second observation that can be drawn from the publications is a greater number of complications in the endovascular repair group than in the open surgery group. These conclusions for the time being suggest that endovascular repair should be reserved for a subset of patients whose anatomy allows stent implantation and who following thorough investigations and information accept the late inconvenience of the endovascular approach.
One of the main differences between the two methods is the fate of the aneurysmal pouch, which is removed during open surgery and is left in place with endovascular repair. It has been demonstrated that endovascular stent grafting was followed by an acute phase inflammatory response (endotoxinemia, CRP and white blood cell count) that was of a lesser magnitude than the one observed after open surgery. Several mechanisms have been implicated as potential triggers of the inflammatory reaction following stent-graft implantation. They have been related to either the stent-graft itself or to the local reactions of the vessel wall (endothelial reaction with activation of the coagulation cascade) [3–4].
In the long term, the reaction of the aneurysmal pouch may also contribute to the perpetuation of an inflammatory reaction or to the extension of the aneurysmal process. A few years ago Sangiorgi et al. [5] have nicely demonstrated that metalloproteinases (MMPs), which contribute to the degradation of the matrix proteins in the aortic wall, could still present a certain degree of activity that was related to the fate of the endovascular repair. Indeed, patients with plasma levels of MMPs that did not return to basal levels were more prone to develop endoleaks and aneurysm expansion. However, MMPs appear to remain elevated for at least three months in open surgery while they return to baseline more rapidly following endovascular graft implantation [6]. Other markers of potential predictive value were tested for the detection of potential endoleak development following stent-graft treatment. Cross-linked fibrin degradation products (D-Dimer) appear to offer such an interesting potential in this surgical population. An increase in D-Dimer after endovascular treatment allowed identification of patients with endoleaks [7].
In the context of the inflammatory response caused by stent-graft repair of aortic aneurysm, Gabriel et al. [8] provide an interesting study looking at the time course of several relevant parameters involved in the inflammatory reaction after endovascular repair of aortic aneurysm repair. They have looked at the immediate, sub acute and late phase, changes of the different mediators and effectors of the inflammation. This carefully performed study will provide a benchmark for the evaluation of the inflammatory reactions following endovascular repair of aortic aneurysm. Unfortunately, the limited number of patients included in the study does not allow drawing any conclusion on the potential predictive value of the markers that were investigated. If further studies in this domain are to be planned, the addition of D-Dimer assay in the panel of the markers would be of great interest both for its potential predictive value and because it is a widely accessible marker in most clinical settings.
This study provides a nice illustration of the kinetics of events that occur after stent implantation. The elevation of IL-6 which culminates at 24 h triggers both an elevation of CRP and the development of fever 24 h later. The erythrocyte sedimentation rate follows the same trend with a lag time of a few days.
Future trials will help the medical community defining the patient population that will benefit most from endovascular repair. Once treated, the patients will have to undergo repeated controls to assess aneurysm tightness and lack of expansion. The monitoring of pertinent inflammatory markers may reduce the need for expensive imaging techniques in this regard. The study by Gabriel et al. provides a valuable dataset that will be useful for the design of future studies aimed at defining the best predictor of successful aortic aneurysm repair by the endovascular approach.
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