We appreciate Dr Buskens' discerning comments and questions.
Although our study was indeed an observational registry-based study,
it is likely the largest cohort of its kind and represents the early outcomes of the vast majority of EVARs performed in the United States over the last 5 years.1 Most other studies compare smaller populations, are restricted to major academic centers, and have highly selected patients and operators.2- 5 Our findings, however, confirm those of other large observational studies, which have clearly established that the high 30-day and in-hospital mortality reported in the EVAR trial 2 is not seen in the United States,
even in the highest-risk patients or those unfit for open repair.2,3 Although no randomized trial,
except for EVAR 2, has assessed the perioperative outcomes of EVAR among the highest-risk patients, the immediate need of data that could justify its use warranted additional investigation in the United States to define health care policy. In this regard, we do agree with Dr Buskens that the proper basis for health care policy definition needs to include the results of several studies that reflect the outcomes and current practices in a particular country. Our study, in conjunction with others, has clearly proven that the perioperative mortality of EVAR in the United States is low, even in the highest-risk patients.
Our conclusion, ie, that EVAR should not be denied to high-risk patients with abdominal aortic aneurysm in the United States on the basis of the level 1 evidence from the British study, is therefore supported by others.2,3