Abstract
ObjectivesA growing number of abdominal aortic aneurysms with severe angulated neck anatomy is treated by endovascular means. However, contradictory early and late outcomes have been reported. Our review and outcome analysis attempted to evaluate the available literature and provide clinicians with a base for clinical implementation and future research.Materials and methodsA systematic review of the literature was undertaken to identify the outcomes of endovascular aneurysm repair in patients with severe infrarenal neck angulation (SNA ≥ 60°) vs non-severe neck angulation (NSNA). Outcome measures included perioperative complications, type 1a endoleak, neck-related secondary procedures, stent graft migration, aneurysm rupture, increase (>5mm) in sac diameter, all-cause and aneurysm-related mortality (PROSPERO Nr.: CRD42021233253).ResultsSix observational studies reporting on 5981 patients (1457 with SNA and 4524 with NSNA) with a weighted mean follow-up period of 1.8 years were included. EVAR in SNA compared with NSNA was associated with a higher rate of type 1a endoleak at 30 days (4.0% vs 1.8%; p< 0.00001), at 1 year (2.8% vs 1.9%; p<0.03), at 2 years (4.9% vs 2.1%; p< 0.0002), at 3 years (5.6% vs 2.6%; p< 0.0001). The rate of neck-related secondary procedures was significantly higher at 1 year (6.6% vs 3.9%; p<0.05) and at 3 years (13.1% vs 9%; p<0.05). Graft migration, aneurysm sack increase, aneurysm rupture and all-cause mortality were not statistically different at mid-term.ConclusionsThe use of EVAR in severely angulated infrarenal aortic necks is associated with a high rate of early and mid-term complications. However, aortic related and all-causes mortality are not higher compared to patients with NSNA. Therefore, EVAR should be cautiously used in patients with SNA.
Highlights
Endovascular aortic repair (EVAR) of abdominal aortic aneurysms (AAA) with severe angulated infrarenal necks is point of discussion since its introduction as a feasible procedure [1].Infrarenal aortic angulation has a negative impact on proximal graft fixation and in patients with severe neck angulation (SNA) it can lead to type 1a endoleak [2,3,4]
EVAR in SNA compared with nonsevere neck angulation (NSNA) was associated with a higher rate of type 1a endoleak at 30 days (4.0% vs 1.8%; p< 0.00001), at 1 year (2.8% vs 1.9%; p
The use of EVAR in severely angulated infrarenal aortic necks is associated with a high rate of early and mid-term complications
Summary
Endovascular aortic repair (EVAR) of abdominal aortic aneurysms (AAA) with severe angulated infrarenal necks is point of discussion since its introduction as a feasible procedure [1]. Infrarenal aortic angulation has a negative impact on proximal graft fixation and in patients with severe neck angulation (SNA) it can lead to type 1a endoleak [2,3,4]. Adjunctive procedures including an aortic extension, bare metal stent (BMS), or endoanchors are used intraoperatively to avoid or treat a type 1a endoleak while fenestrated grafts or chimney’s may be used to treat a type 1a endoleak postoperatively [5]. Other suprarenal solutions like use of fenestrated grafts and the chimney technique have been described for treating persistent type 1a endoleak. To our knowledge only a few studies with small sample sizes and with conflicting results have been published [6,7,8,9,10,11]
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