The use of endovascular aneurysm repair (EVAR) in the treatment of abdominal aortic aneurysms has advanced from a premature characterization as a “failed experiment” in early 2000 to the predominant modern method of treatment. Technology has accommodated initial shortcomings, but it has also led to expansions in the treatment of ruptured aneurysms and complex aortic pathologies. The overall aim of this thesis is to characterize the contemporary utilization of endovascular repair in the international setting and to evaluate its expanding use in complex aortic disease treatment.

Paper I is an analysis of outcomes after intact aneurysm treatment from registries of 12 countries. From 2005 to 2013, and with 83,253 patients included, it was shown that the use of EVAR has increased while, the perioperative mortality has decreased. This was counterbalanced by a worsening mortality for those patients treated with open aortic repair.

Paper II is an analysis of ruptured aneurysms from the above-mentioned international registries. EVAR is also increasing for these patients, although open repair is still the predominant treatment strategy in most centres. Perioperative mortality was superior for EVAR patients, despite increased age and comorbidities. An association between patient-volume and perioperative mortality could be shown for open repair, but the same could not be demonstrated for EVAR.

Paper III is an evaluation of the adaptation of a total endovascular approach for the treatment of complex abdominal aortic aneurysms from a single centre. The technical success and midterm mortality, as well as post-operative complications, including spinal ischemia, were similar to those reported from large and multi-centre analyses. Previous studies reveal disparate results for centres performing open complex aortic repair. The results here suggest that a total endovascular approach is feasible for dedicated centres contemplating this strategy.  

Paper IV is an analysis of multiple pre-, peri-, and post-operative variables documented from complex aneurysm procedures. A relationship between increased complexity and variables such as anaesthesia duration, bleeding, hospital stay, and radiation exposure was found. As patients and their comorbidities increase, a decision to embark on a complex procedure should be made with due diligence to these relationships.

Paper V is a technical analysis of patients following acute treatment for Type A aortic dissections. Many patients are unfit for open aortic arch repair. Based on current availability of endovascular aortic stentgrafts, it was shown that the majority of patients can be treated endovascularly, while anticipated device improvements should further increase the proportion of eligibility.