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Lederle FA, Freischlag JA, Kyriakides TC, and the OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2012;367:1988-97. Conclusion:Endovascular and open repair of abdominal aortic aneurysm (AAA) have similar long-term survival. In those aged <70 years, survival tends to be better with endovascular repair, whereas in those aged >70 years, survival appears improved with open repair.Summary: With the exception of colectomy, aneurysm repair results in more perioperative deaths than any other general or vascular surgical procedure, w1250 perioperative deaths per year (Ghaferi AA et al, N Engl J Med 2009;1361-8-75). Randomized trials have demonstrated decreased perioperative mortality in patients undergoing endovascular AAA repair. This survival advantage in the United Kingdom EVAR 1 trial and the Dutch DREAM trial was lost #2 years due to excess late deaths in the endovascular repair groups (The United Kingdom EVAR Trial Investigators, N Engl J Med 2010;362:1863-71; De Bruin JL et al, N Engl J Med 2010;362:1881-9). In the Veterans Affair Cooperative Study of Open vs Endovascular Repair (OVER), excess late deaths in the endovascular groups were not noted at 2 years (Lederle FA et al, JAMA 2009;302:1535-42). The authors of this study present the longer-term results of the OVER trial. In the trial, 881 patients with asymptomatic AAAs who were candidates for open or endovascular repair were randomized to endovascular repair (n ¼ 444) or open repair (n ¼ 437). Followup is for up to 9 years (mean, 5.2 years). Forty-two Veteran's Affairs medical centers participated in the trial, and all patients were aged $49 years at entry into the trial. More than 95% of patients underwent the assigned repair. The primary outcome was all-cause mortality, and 146 deaths occurred in each group (hazard risk [HR] with endovascular repair vs open repair, 0.97; 95% confidence interval [CI], 0.77-1.22; P ¼ .81). The previously reported reduction in perioperative mortality with endovascular repair was sustained at 2 years (HR, 0.63; 95% CI, 0.40-0.98; P ¼ .04) and at 3 years (HR, 0.72; 95% CI, 0.51-1.00; P ¼ .05) but not thereafter. In the endovascular repair group there were 10 aneurysm-related deaths (2.3%) vs 16 in the open repair group (3.7%; P ¼ .22). Six aneurysm ruptures were confirmed in the endovascular repair group vs none in the open repair group (P ¼ .03). A significant interaction was observed between age and type of treatment (P ¼ .006). Survival was increased among patients aged <70 years in the endovascular repair group but tended to be better among those aged >70 years in the open repair group. The two groups did not differ significantly with respect to number of secondary therapeutic procedures, number of hospitalizations after repair, quality of life, or erectile dysfunction.Comment: Perhaps the most surprising finding in this study was that endovascular repair appears to result in better outcomes among younger patients and in worse outcomes among older patients. The reasons for this are unclear, but perhaps older ...

Background:In the treatment of patients with unstable angina and non-ST segment elevation myocardial infarction (UA/NSTEMI), debate exists as to whether an early invasive vs. a conservative strategy is optimal therapy. Methods: In the international TACTICS-TIMI 18 trial, 2220 patients with UA/NSTEMI who had either electrocardiographic changes, elevated cardiac markers or a history of prior coronary artery disease, were immediately treated with aspirin, heparin and the glycoprotein (GP) IIb/IIIa inhibitor tirofiban. They were randomized to an early invasive strategy with routine catheterization and revascularization as appropriate within 4 -48 hours, or to a conservative, or "selective invasive" strategy, with catheterization performed only if the patient had objective evidence of recurrent ischemia or a positive stress test. The primary endpoint was a composite of death, myocardial infarction or rehospitalization for acute coronary syndromes at 6 months. Results: The rate of the primary endpoint was significantly reduced with the invasive strategy compared to the conservative strategy, 15.9% vs. 19.4%, odds ratio (OR) 0.78, pϭ0.025. The rate of death or MI at 6 months was also significantly reduced (9.5% vs. 7.3%, respectively, OR 0.74, pϽ0.05). Conclusion: In patients with UA/NSTEMI treated with the GP IIb/IIIa inhibitor tirofiban, an early invasive strategy resulted in a significant reduction in major cardiac events. These data suggest a need to update the ACC/AHA Unstable angina Guidelines, and to modify the clinical approach to managing unstable angina with broader use of an early invasive strategy with upstream GP IIb/IIIa inhibition.