A meta-analysis of safety and efficacy of endovascular aneurysm repair in aneurysm patients with severe angulated infrarenal neck

Abstract

Objectives A 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 methods A 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). Results Six 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. Conclusions The 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.

Results of the Chimney Technique in a Community Hospital

“…Late onset EL1A is an uncommon complication after EVAR, with an incidence of 1-5%. [22][23][24] It is associated with continued sac expansion and risk of rupture. 25,26 There are studies which suggest that primary EL1A, defined as EL1A at the completion angiography, has a more mild course when compared to late onset EL1A.…”

Endovascular management of aortic aneurysm with severe neck angulation and/or iliac artery tortuosity using multiple stiff wire technique: a case series

“…A single-center study in Greece by Karathanos et al found that 34 of 317 EVAR patients (10.7%) had a neck angle >60°. 9 EVAR with severe neck angulation compared to non-severe neck angulation was associated with a significantly higher rate of type 1a endoleak until 3 years (5.6% vs 2.6%; p<0.00001; OR 2.57 95% CI 1.62-4.07), neck-related secondary procedure until 3 years (13.1% vs 9%; p<0.05; OR 1.42 95% CI 1.04-1.96), migration rates until 1 year (5.4% vs 4.0%; p<0.05; OR 1.41 95% CI 1.03-1.94), aneurysmrelated and all-cause mortality until 1 year (6.4% vs. 4.3%; p<0.05; OR 1.51 95% CI 1.16-1.98), but not related to aneurysm sac increase and rupture. 10 High-tortuosity neck in TEVAR also has its problem related to a significantly higher proportion of endoleaks, a potential risk factor for proximal stent-graft collapse or infolding, renal failure, stroke, longer operation time, and lower survival rate.…”

The Challenge of Treating Abdominal Aortic Aneurysms with Hostile Neck Anatomy: An Overview

“…Two suprarenal platforms are approved for up to 75 degrees: the Treovance ™ (Terumo Aortic, Sunrise, FL, USA) and the Endurant II ™ (Medtronic Cardiovascular, Santa Rosa, CA, USA) systems. The infrarenal systems Anaconda ™ (Terumo Aortic, Glasgow, UK), Aorfix ™ (Lombard Medical, Didcot, UK), and the Conformable Excluder C3 device ™ (WL Gore & Associates, Flagstaff, AZ, USA) extend their IFU up to 90 degrees [ 25 ]. Midterm data for the Aorfix device show promising results, demonstrating no difference in sac expansion or regression in necks ≥ 60 degrees [ 26 ].…”