In one of the more light-hearted moments from the meeting, Kenneth Ouriel acted as moderator for a session entitled, “Should small aneurysms be treated with endografts?” Following introductory comments from Ouriel, Dr Juan Parodi said that the results from the UK Small Aneurysms Trial and ADAM did not conclusively show endografts to be the “go-to therapy” for small aneurysms, and although mortality rates did favour endografts, there was still much work to be done.
Speaking in favour of early intervention, Dr Daniel Clair, defined a small aneurysm as less than 5.5cm, although even aneurysms measuring 5cm are not necessarily small. Clair cited a previous a previous study by Frank Veith, speaking against early intervention, which said that maximum AAA diameter measurements can vary by as much as 1.5cm. He said that although the ADAM and the UK small aneurysms trials showed no benefit to early open repair, the results from these trials cannot be extrapolated to endovascular aneurysm repair.
Clair mocked Veith and depicted him as the Simpson character Mr Burns. Clair stated that the survival curves of the studies cross at three years and statistically differ at eight, “Dr Veith thinks this is exxxcellent,” he announced to the delighted audience. He ended by saying that VEITH stood for the Vigorous Examination In Treatment Hypothesis.
In addition, Clair also mocked commenter, Dr Alan Lumsden, stating that he is “Leading Us into Making Stupid Decisions regarding Endovascular Management,” – although, this does not work as an acronym!
In response, Veith said that there was good information that early intervention was not needed, except in unusual circumstances. These included; nervous patients, a tender AAA and small patients (females). Veith poked fun at Clair by adding that intervention is also justified if the “surgeon is impoverished, cannot feed his family, needs a new car – or a bigger vineyard!” Veith joked that Clair was a closet wine-maker and vineyard owner who was eyeing a bigger plot of land for his crops, “I think we can all see that Dan needs a bigger vineyard!” Veith added that there was no level one, two or three evidence – only “Clairian level” evidence. Although he acknowledged, albeit reluctantly, that a randomised control trials for intervention in small AAA’s was justified. Lumsden retorted that on the strength of his presentation, Clair stood for; Clearly Lost All Integrity and Reason.