New-generation Devices for Highly Angulated Aortic Necks: To Bury or to Praise Endovascular Aneurysm Repair (EVAR)?

Abstract

The early results of the Arbiter 2 study, published in this issue of EJVES, showed as recent improvements gained with newgeneration aortic stentgrafts allowed endovascular aneurysm repair (EVAR) to better deal with difficult anatomy. The Aorfix modular device (Lombard Medical Technologies) was shown to be successfully applied in aneurysmswith excessive neck angulation, mainly 75 and even >90 (!). Unfortunately, only 30 cases were studied in this pilot study and assessment stopped early, providing only short-term results. Despite the extremely adverse anatomy, initial technical success was achieved in 93.3% because of two immediate migrations. No subsequent migrations were observed; however, procedure was associated with 3% perioperative mortality, 17% morbidity and approximately 7% type I endoleak and 10% mortality at 6 months. At this point, will any aggressive refinement in stentgraft technology to treat abdominal aortic aneurysms (AAA) with unfit anatomy be worthwhile? Some important messages could be provided by the Arbiter 2 study to this regard. The first is that technology for EVAR stentgraft has substantially improved in the last few years, providing models with certainly superior results, not hoped before. Fortunately, EVAR, even in its maturity, is ‘a work in