What procedures can be used for aneurysm repair?

What procedures do you usually do? In terms of aneurysm repair, up and down the country at the moment it's probably about endovascular, probably still over 60-65% and then open, it's obviously 35-40% but that is changing slightly over the last 10 years been a swing to more endovascular and that's swinging back now as we've seen some durability problems. Within the screened population, which is a younger cohort because they're mid-60s, they are 50-50. So there's a much greater proportion having open surgery, even though open surgery is associated with more upfront risks and complications, the durability benefit is more important for a younger age group because now once those patients have given up smoking, their risk factors are controlled, their colon cancer may have been found and treated, they've had their coronary artery bypass done, their longevity is much greater than it was 20, 30 years ago. So it is no good than having a procedure which doesn't last with their lifespan and require then more invasive treatments perhaps 10 years down the line. What perhaps is different is for an emergency presentation with a rupture aneurysm. We've already talked about the fact that of those patients, the mortality is about 80%. However, of those patients arriving in hospital, there is a chance of them surviving, and broad brush figures would suggest that perhaps the mortality of someone who arrives alive in hospital with a ruptured aneurysm is about 30%. So yes, you know, still a high risk that 70% may survive and under those circumstances the advantage of an endovascular approach as long as their anatomy is suitable becomes more important because their main risk is in the next 24-48 hours so you're not so worried about durability then all you need to do is get them to survive and there was a very good trial done in the UK recently called the IMPROVE trial which looked at this and actually the benefits to an endovascular approach in a ruptured aneurysm are probably greater. The frustration is that of ruptures a reasonable portion of them are not ideally suitable for standard off-the-shelf endovascular stents and therefore they still need open surgery and when patients are really physiologically deranged having had a massive bleed open surgery isn't associated with great outcomes because again these are people with poor lung disease, heart disease and having a massive operation in difficult circumstances without having had the optimization that an elective patient may have because if we get referred an elective patient we have a chance to do an MOT because there's no point in repairing one bit of their body and ignoring the fact that they've got significant ischemic heart disease or lung disease which could be optimized so they tend to have an assessment of their heart, lungs, kidneys to see if there's anything which could be improved to get them through surgery. And then also simple measures such as increasing their exercise, weight loss, giving up smoking, getting them onto the right medication, all have a chance to both improve their long-term lifespan, which is crucial because there's no point in them having a major intervention and then succumbing to something else which could have been correctable plus getting them as fit as possible to get them through that hospital episode and get them home as quickly as possible.