Endograft Shortening During Endovascular Repair of Abdominal Aortic Aneurysms in Severe Aortoiliac Tortuosity

Abstract

Severely tortuous aortoiliac anatomy can influence the deployment of the endograft during endovascular abdominal aortic aneurysm repair (EVAR) and have a negative impact on distal fixation. The purpose of this study was to determine how severe aortoiliac tortuosity can change an aortic endograft's length and how it affects distal fixation. A retrospective review of a prospectively collected vascular surgery database at a university-affiliated medical center was used to identify the study patients. The goal was to identify patients who underwent EVAR with the main body device deployed to a severely tortuous iliac artery. Severe aortoiliac tortuosity was defined as aortoiliac or iliac angulation of <90°. Patients were excluded if more than one device was deployed distal to the main body device, which made accurate lengths measurements difficult. A total of 469 patients underwent EVAR between 2008 and 2014. Of the 171 patients with severe aortoiliac tortuosity, in only 18 patients was the main body placed on the side of severe tortuosity without an extension limb. The mean length of the main body for EVAR was 169 mm, and this length significantly shortened to 147 mm once it was placed in the severely tortuous AAA (P < .001). Treatment length of the main body side measured from the lowest renal artery to the iliac bifurcation also significantly shortened from 179 mm to 170 mm (P = .001). The most angulated portion of the artery on the main body side became significantly less post-EVAR, changing from 86° to 114° (P < .001). Analysis of the nontortuous side showed a nonsignificant change in treatment length (P = .859) and angulation (P = .195). Severe aortoiliac tortuosity can cause significant shortening of endografts, which can negatively impact distal fixation during EVAR. Consideration for a longer main body or an extension limb should be given in tortuous aneurysms.