This study states that Modern observational studies have confirmed that the perioperative morbidity and mortality of EVAR are unquestionably better than those of OSR for all patients2; however, the long-term outcomes remain unclear. The rates of secondary interventions after EVAR have improved over time but have remained greater than those after OSR, although most are for minor endovascular procedures.2,3

We believe that clinical equipoise for a new trial does not exist. Ethically, the long-term benefits for OSR must be potentially clinically significant enough to offset the known perioperative morbidity and mortality benefits of EVAR. Furthermore, the willingness of physicians and patients in the general population to randomize (or adhere to randomization) is likely to be low given the current status of EVAR as the de facto standard for anatomically appropriate patients.

However, certain populations exist in which equipoise between OSR and EVAR might be found. We have shown that for patients aged <70 years, the perioperative mortality is clinically insignificant for both surgical methods, with mortality rates <1%.

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