Is the Reevaluation of Cardiac Status and Medical Treatment Mandatory for Patients With Coronary Artery Disease After Endovascular Aneurysm Repair?

Over the past 2 decades, endovascular aneurysm repair (EVAR) has become established as the treatment of choice for abdominal aortic aneurysm (AAA) in many vascular centers instead of the traditional open repair. However, in recent studies, there was no difference in the long-term survival between the 2 treatments. The important commonality for both treatments is the cardiovascular morbidity and mortality. This is reasonable because AAAs positively correlate with the presence of coronary artery disease (CAD). A prevalence of AAAs as high as 18.2% has been reported in patients undergoing coronary artery bypass grafting. In addition to that, the prevalence of CAD in patients suffering from AAAs reaches to 53%. EVAR and open repair are indeed effective treatment options for AAA, but related changes in cardiac status and arterial stiffness are not well established. The proximal aorta is a highly compliant vessel, which reduces left ventricle (LV) workload and dampens the propagated pressure wave. After EVAR or open AAA repair, the interposition of prosthetic stent-grafts and grafts, respectively, may acutely reduce the compliance. As a result, the input impedance is significantly increased and systemic arterial compliance is significantly decreased, with a subsequent increase in systolic and pulse pressures leading to left ventricular hypertrophy. Thus, EVAR or open repair may have an adverse effect on cardiovascular hemodynamics, which in turn may lead to hypertension, cardiac hypertrophy and ischemia, the development of vessel wall disease, and thrombosis formation. In the past, studies have investigated the hemodynamics of thoracic aortic aneurysms (TAAs) and AAAs after endovascular or open repair, and the research in this field is still ongoing. However, most of the studies have been related to AAAs because of their higher incidence. Such studies have been based on 3-dimensional (3D) simulations with good reproduction of the pressure and flow waveforms of the aorta during the cardiac cycle. Nowadays, temporal variation and spatial patterns of wall shear stress are presented in the aortic arch and thoracic aorta together using rigid wall and 3D fluidstructure interaction (FSI) models or even dynamic magnetic resonance angiography (MRA) and wall motion tracking software. However, the clinical significance for patient outcome and follow-up as regards the cardiac and blood pressure level changes after the procedure have not been adequately assessed for patients with CAD suffering from AAA. It is clear that vascular stiffness, LV hypertrophy, and diastolic dysfunction are increased after EVAR. First, elevated aortic vascular stiffness is indicated by the postEVAR elevation in the ankle-brachial pulse wave velocity (baPWV). The LV mass index (LVMI) increases significantly after EVAR, and these changes are positively correlated with those in baPWV. Studies have shown that arterial stiffness is associated with LV hypertrophy, which has been linked to increased risk of atherosclerotic heart disease, myocardial infarction, and stroke. PWV is also increased due to graft interposition in open repair, and it does not significantly differ from PWV changes after EVAR, although there is a study that suggests that stent-grafts increase reflected waves more than graft prostheses. Additionally, there is a difference between 573248 JETXXX10.1177/1526602815573248Journal of Endovascular TherapySpanos and Giannoukas research-article2015