Is Evar Feasible in Challenging Aortic Neck Anatomies? A Technical Review and Ethical Discussion

Abstract

Background: Endovascular aneurysm repair (EVAR) has become an accepted alternative to open repair (OR) for the treatment of abdominal aortic aneurysm (AAA) despite “hostile” anatomies that may reduce its effectiveness. Guidelines suggest refraining from EVAR in such circumstances, but in clinical practice, up to 44% of EVAR procedures are performed using stent grafts outside their instruction for use (IFU), with acceptable outcomes. Starting from this “inconsistency” between clinical practice and guidelines, the aim of this contribution is to report the technical results of the use of EVAR in challenging anatomies as well as the ethical aspects to identify the criteria by which the “best interest” of the patient can be set. Materials and Methods: A literature review on currently available evidence on standard EVAR using commercially available endografts in patients with hostile aortic neck anatomies was conducted. Medline using the PubMed interface and The Cochrane Library databases were searched from 1 January 2000 to 6 May 2021, considering the following outcomes: technical success; need for additional procedures; conversion to OR; reintervention; migration; the presence of type I endoleaks; AAA-related mortality rate. Results: A total of 52 publications were selected by the investigators for a detailed review. All studies were either prospective or retrospective observational studies reporting the immediate, 30-day, and/or follow-up outcomes of standard EVAR procedures in patients with challenging neck anatomies. No randomized trials were identified. Fourteen different endo-grafts systems were used in the selected studies. A total of 45 studies reported a technical success rate ranging from 93 to 100%, and 42 the need for additional procedures (mean value of 9.04%). Results at 30 days: the incidence rate of type Ia endoleak was reported by 37 studies with a mean value of 2.65%; 31 studies reported a null migration rate and 32 a null conversion rate to OR; in 31 of the 35 studies that reported AAA-related mortality, the incidence was null. Mid-term follow-up: the incidence rate of type Ia endoleak was reported by 48 studies with a mean value of 6.65%; 30 studies reported a null migration rate, 33 a null conversion rate to OR, and 28 of the 45 studies reported that the AAA-related mortality incidence was null. Conclusions: Based on the present analysis, EVAR appears to be a safe and effective procedure—and therefore recommendable—even in the presence of hostile anatomies, in patients deemed unfit for OR. However, in order to identify and pursue the patient’s best interest, particular attention must be paid to the management of the patient’s informed consent process, which—in addition to being an essential ethical-legal requirement to legitimize the medical act—ensures that clinical data can be integrated with the patient’s personal preferences and background, beyond the therapeutic potential of the proposed procedures and what is generically stated in the guidelines.

Selective aneurysmal sac neck-targeted embolization during endovascular repair of abdominal aortic aneurysm with hostile neck anatomy

“…Numerous studies have demonstrated that standard EVAR for AAA patients with an HNA can nevertheless achieve satisfactory long-term outcomes, confirming the efficiency of EVAR in cases of unfavourable morphologies [ 15 , 16 ]. However, the increased incidence of ELIa has been linked to a hostile neck anatomy due to an insufficient seal between the aortic wall and the endograft attachment sites [ 8 , 17 ].…”

Selective aneurysmal sac neck-targeted embolization during endovascular aneurysm repair of abdominal aortic aneurysm with hostile neck anatomy

“…Numerous studies have demonstrated that standard EVAR for AAA patients with a hostile neck anatomy can nevertheless achieve satisfactory long-term outcomes, con rming the e ciency of EVAR in unfavorable morphologies. 14,15 However, the increased incidence of type Ia endoleak was linked to a hostile neck anatomy, which resulted from an insu cient seal between the aortic wall and the endograft attachment sites. 8,16 This retrospective study assessed the short-term e cacy and safety of intraprocedural selective coil embolization of the aneurysmal sac neck to eliminate persistent type Ia endoleak in endovascular repair of AAA with hostile neck morphology.…”

Please, Look Beyond. Comment on ‘‘Chimney Versus Fenestrated Endovascular Versus Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms: Systematic Review and Network Meta‐Analysis of the Short‐Term Results’’

“…However, as for standard EVAR in challenging anatomies [3], the main disquietude regarding complex endovascular aortic repair procedures should be represented by the mid‐ and long‐term follow‐up.…”