Sandmann calls for endovascular caution


Vascular News spoke to Wilhelm Sandmann who recently had a paper published in the Deutsches Aerzteblatt. He felt that this was the right time to write about endovascular endografting. His main message is that “still today endovascular AAA should not be recognised as a standard procedure. He said that stent grafting is overdone, fuelled by industry, and that it has not been shown that mortality and morbidity can be reduced: “I am not against endovascular therapy but the widespread usage is not justified. Twelve-month follow up is not enough. Everyone is afraid that if they do not offer the endovascular approach that they will get fewer patients than before.

Sandmann questioned whether intervention is often even justified: “The goal is freedom from rupture, but rupture in six years is as high as without treatment. Yet Stelter shows a row of men ready to die in whom there is no sense to insert an endoprosthesis. “He also attacked the claims of Wolf Stelter that conventional surgery is dead and his rejection of the need for a prospective randomised trial. According to Stelter, those pushing for a randomised controlled trial can see the train pulling out of the station and want to jump on the last carriage.

Sandmann and Tomas Pfeiffer analysed the current literature to see if their sceptical attitude towards the endovascular method is still justified. A meta-analysis in 1998 including 41 studies with 13,696 patients showed an average mortality of 3.8% in elective open surgery. The average mortality of endovasacular treatment of AAA in 101 centres including 3,413 patients was reported to be 2.8% in 2001. Comparative studies have demonstrated similar mortalities.

A meta-analysis of 23 studies with 1,118 patients found the incidence of persisting endoleaks and secondary leakages after endovascular therapy to be 9% and 8%, respectively.

Sandmann’s paper is well researched with an extensive list of 115 references. However, other sources have indicated to Vascular News that contrary to a statement in Sandmann’s paper that “Late complications after open AAA surgery are rare. A postoperative rupture of an AAA has not been reported to date,”there are two references from the Journal of Vascular Surgery that show otherwise; Johnston KW et al., J Vasc Surg 199, 20:163-70 and Williamson WK et al., J Vasc Surg, 33:913-20.

Sandmann may be pouring cold water on endovasular aneurysm repair but he is upbeat about the future of conventional vascular surgery. There is an increasingly ageing population and allied with the fact that patients come too late, very often the endovascular approach is not an option.