INTRODUCTION: BACKGROUND AND JUSTIFICATION

The Society of Cardiovascular Surgery and the Chapter North-American of The International Cardiovascular Society defines aneurysm as a permanent localized dilatation of an artery, having at least a 50% increase in diameter compared with the expected normal diameter[i]. If there is no adjacent normal artery segment, this definition must rely on an estimate of the expected normal diameter[ii].  Normal arterial diameter depends on age, gender, body size, and other factors.

Untreated, the major complication is rupture leading to death. Aneurismal rupture is directly related to aneurysm size, according to LaPlace’s Law that tension on the aortic wall is the product of the artery’s radius times blood pressure[iii]. Indications for repair in patients with AAA include[iv] diameter of 5 cm or larger (4.5 to 5.0 for women), growht rate > 10 mm/year and symptoms related to the aneurysm

The abdominal aortic aneurysm is one of the most studied because of his bigger incidence on the population (it affects about 5% to 7% of world population). Generally, abdominal aortic aneurysm is 5 times more common in men than in women. In men, the process appears to begin at approximately age 40 years and reaches peak incidence from 75 to 79 years.

            In women, the onset is delayed and appears to begin at approximately age 60 years.

Treatment can be done by different types of surgery: OPEN surgery and EVAR surgery.

 Open surgery was reported firstly in 1951 and has evolved and significant improvement in mortality and morbidity rates has been achieved. However, even in low risk patients, open repair of AAA is associated with a mortality rate of 0 to 5%[v]. The use of endovascular grafts has attracted wide attention over the last decade because of the less invasive nature of procedure. In 1991 happened the first successful implantation of an endoluminal stent-graft in patient with an infrarenal AAA[vi]. Choose which one is recommended for this type of pathology is a hard work, which needs to analyse a list of different aspects, such as the quality of life, precedents pathology and clinical history of the patient, etc. Nevertheless, there is controversy on this matter.

Recent studies suggest that EVAR surgery might reduce perioperatory mortality of ruptured AAA and it can reduce recovery time to two or three days, but it carries more needs of vigilance and secondary reinterventions than OPEN surgey. Besides, it’s more expensive. Other studies claim that, after on year, the level of quality of life among patients submitted to OPEN and EVAR surgery is not so different. (Borchard, Scott and Stary, 2004). Early mortality data for EVAR have been generally less than 3%. Some studies, such as AneuRx phase I, II, III[vii] and EUROSTAR have shown that mortality resultant of EVAR is less than that of open surgical repair[viii]. However, when the matter is long-term survival, open repair related studies are more well defined than EVAR studies.

Three randomized control trials of EVAR were performed: EVAR 1[ix], EVAR 2[x] and DREAM Study (Dutch Randomized Endovascular Aneurysm Management)[xi] . EVAR 1 randomly assigned 1082 patients to undergo either therapy of EVAR of AA or open repair. A difference from other studies is that in this study patients were candidate for both procedures. 4 years after randomization, the rate for all-cause mortality was similar in the two groups, but there was a persistent reduction in aneurysm-related deaths in the EVAR group. On the other hand, EVAR 2 randomly assigned patients who evaluated for EVAR 1 as too high risk for open repair to undergo either EVAR or medical management. The initial high rate for operative mortality in the EVAR group resulted in no late difference in aneurysm-related mortality or overall survival. But, indeed, two things in this study made that conclusions could not be so easily achieved:  first, two14 deaths in the EVAR group happened after randomization but before intervention, 6 of them of ruptured AAA; second, 47 patients in the medical management had to undergo subsequent intervention (12 open repair and 35 EVAR). Finally, the third randomized study controlled trial was the DREAM Study. This study was about 345 patients, whose AAA had a diameter of > 5cm were suitable for making them candidates for either of the two techniques. In the endovascular-repair group the rate of operative mortality and severe complication was 4.7 %; in the open repair group the combined rate was 9.8%. two years after randomization, endovascular repair was found to have a clear advantage over open repair that was accounted for entirely by events occurring in the perioperative period: an equally good cumulative survival rate (89.6% versus 89.7%) but a much better cumulative rate of aneurysm related death (2.1% versus 5.7%)[xii] 

Quality of life is obviously difficult to define and measure. The World Health Organisation defines “health” as a state of physical, mental and social well-being, not merely the absence of disease. ^[xiii] According to the published literature, a difference of less than 10% in QOL measures is not clinically important and meaningful.

Quality of life assessment tools such as the SF-36 can help surgeons evaluate a patient’s perception of his or her health and well being before and after surgery.^[xiv],[xv] The standardized SF-36 health survey is a valuable instrument to measure patient – perceived quality of life owing to its high validity, reliability, psychometric property.^[xvi],[xvii] The American College of Surgeons and the American Society of Vascular surgery have both promoted the use of SF-36 in the surgical population,[xviii] and the SF-36 has been validated for patients with vascular diseases.

It’s precisely because of these reasons above (the high frequency of AAA around the world and mostly among men in specific ages an the eventual differences in the QOL after both surgical interventions) that it’s been decided to work on a paper which is going to focus on a specific type of aneurysm, the abdominal aortic aneurysms, and the Quality of Life (according to SF-36 questionnaire) in patients over 40 years submitted two different types of surgery repair, OPEN surgery and endovascular aneurysm repair(EVAR).