RS13. Standard Endovascular Aneurysm Repair in Patients With Wide Proximal Aneurysm Necks Is Associated With Increased Risk of Adverse Events

Abstract

Endovascular aneurysm repair (EVAR) has progressively expanded to treat progressively more challenging anatomies. Although EVAR in patients with large proximal necks has been reported with acceptable results, there is still controversy regarding the midterm outcomes. Our aim is to determine the impact of proximal neck diameter on midterm outcome after EVAR with a single endograft with suprarenal fixation. A retrospective case-control study was designed using data from a prospective multicenter database. All measurements were obtained using dedicated reconstruction software and center-lumen line reconstruction. Patients who electively underwent standard EVAR with an Endurant stent graft (Medtronic AVE, Santa Rosa, Calif) for a degenerative AAA from January 2008 to December 2012 in three high-volume centers in the Netherlands were included. Patients with a proximal neck diameter ≥30 mm were compared to the remaining population. Primary end point was freedom from neck-related adverse events (type IA endoleak, neck-related secondary intervention, endograft migration >10 mm). Secondary end points were freedom from rupture, type 1A endoleak and neck-related reinterventions. A total of 427 patients were included; of these, 74 patients (17.3%) with a neck diameter ≥30 mm were compared to a control group of 353 patients. Median follow-up was 3.1 years (1.2-4.7) and 4.1 years (2.7-5.6) for the large-neck and control groups, respectively (P < .001). The two groups did not differ regarding demographics, comorbidities, baseline aneurysm diameter (P = .39), proximal neck length (P = .72), suprarenal angulation (P = .76), or infrarenal angulation (P = .99). Mean stent graft oversizing was 13.2% ± 5.2% and 17.8% ± 8.0% in the large-neck and control groups, respectively (P < .001). The 4-year freedom from neck-related adverse-events estimates were 75% and 95% for the large-neck and control groups, respectively (P < .001; Fig). Proximal neck diameter ≥30 mm was associated with a fourfold increased risk of neck- related adverse events in a multivariable model (HR, 4.3; 95% CI, 1.9-9.7; P < .001). Type IA endoleaks occurred in 16 patients (3.7%) and were significantly more frequent in patients with large neck diameters (7 [9.5%]; P = .005). Neck-related secondary interventions were performed in 20 patients (4.7%) and were also more common among patients with neck diameters ≥30 mm (7 [9.5%]; P = .035). Secondary aneurysm rupture occurred in 7 patients but was not associated to large proximal aneurysm neck (P = .82). EVAR in patients with large-diameter necks is associated with an increased risk of neck-related adverse events in midterm follow-up. This may influence the clinical decision regarding choice of repair and towards a more intensive surveillance after EVAR.