Commentary on ‘Morphological Differences in the Aorto-iliac Segment in AAA Patients of Caucasian and Asian Origin’

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The increased incidence of newly diagnosed abdominal aortic aneurysms in the ageing Asian population has raised the question of whether suitability for endovascular aneurysm repair (EVAR) is the same in Caucasian and Asian patients. Banzic et al. present the results of a morphological comparison of the aorto-iliac segment (AAA >5 cm) in 296 consecutive Asian and Caucasian patients from one Chinese and two European centres. The aneurysmneck tended to be shorter and narrowerwith a smaller infrarenal angle in Asian compared with Caucasian patients. The Asian patients also principally had shorter and narrower common iliac arteries (CIA), and narrower external iliac and common femoral arteries. The literature comparing aorto-iliac anatomy between Caucasian and Asian patients is scarce. Previous studies have investigated Chinese, Korean, and Japanese patients and compared the results to similar cohorts with either anatomical measurements by the same authors, or to the published literature. The findings suggest there are differences in aorto-iliac anatomy between the different countries in Asia, as well as differences between Caucasian and Asian patients. Aorto-iliac anatomy is important because it determines the suitability for endovascular aneurysm repair (EVAR), which in turn affects the incidence of perioperative complications and secondary interventions. Reports on anatomical suitability for EVAR are inconsistent, varying between 25% and 66%, with unfavourable iliac anatomy often being the predominant reason for turndown. Asianpopulationson thewhole tend tohave shorter CIA compared with Caucasian patients, which can result in an inadequate distal seal. Extension of the landing zone to the external iliac artery is associated with an increased risk of limb thrombosis and, in the absence of internal iliac artery (IIA) revascularisation, buttock claudication and impotence. An iliac branch device (IBD) can be used to preserve IIA flow but commercially available IBDs require longer CIA than the mean length reported in the paper by Banzic et al. This length is required to allow cannulation and implantation of a bridging stent in the IIA via the contra-lateral iliac artery. Brachial or axillary access can be used but this has been shown to be associated with an increased riskof stroke. The bifurcatedebifurcated iliac device, designed by RK Greenberg, enables implantation of a bridging stent in the IIA via the contra-lateral iliac artery in the presence of short CIA.