Fit 68-year-old with a 5.8 cm infrarenal AAA — EVAR versus open repair choice with the 15-year crossover

Candidate tasks and model management

Justify repair at 5.8 cm, not surveillance. At 5.8 cm he has crossed the randomised threshold: four small-AAA trials with 3314 participants show no advantage to early repair at 4.0 to 5.5 cm, which is exactly why surveillance stops and planned repair starts once the aneurysm exceeds 5.5 cm.^[1] Place him in the VQI medium band (5.5 to 6.5 cm in men) — 30-day EVAR death 0.9% and 5-year survival 81% — worse than the small band he has left, better than the large band ahead.^[25]

Counsel EVAR against open with the full time course, not just the perioperative win. Quote EVAR first: 30-day death 1.8 versus 4.3% (OR 0.39), and OVER's 0.5 versus 3.0% with blood 200 versus 1000 mL, stay 3 versus 7 days and ICU 1 versus 4 days.^[9][11] Then quote the convergence the examiner waits for: 4-year death tied at about 28%, long-term HR 1.03, DREAM 6-year survival 69.9 versus 68.9% tied — with open repair keeping freedom from reintervention at 81.9 versus 70.4%.^[8][9][12] Then deliver the 15-year crossover: EVAR safer at 0 to 6 months (HR 0.61) but open repair safer beyond 8 years (HR 1.25 total, 5.82 aneurysm-related), driven by 13 secondary sac ruptures after EVAR against 2 after open.^[10] For this fit 68-year-old with a long horizon, present open repair as the durability choice and EVAR as the recovery choice — his fitness admits both, his anatomy admits EVAR, and his age makes the late tail matter.^[10][13]

Book surveillance as part of the operation, not an afterthought. After EVAR, lifelong imaging with reintervention: complications appear to 8 years, reinterventions run doubled (OR 1.98), and the sac can still rupture late — name the owner and the interval before he leaves.^[9][13][10] After open repair, the reintervention burden is lower but follow-up still stands. Counsel with the pooled Cochrane frame: short-term 1.4 versus 4.2% favouring EVAR, everything tied thereafter except reintervention.^[13]