Most Patients with Abdominal Aortic Aneurysm Are Not Suitable for Endovascular Repair Using Currently Approved Bifurcated Stent-Grafts

Abstract

Strict morphologic criteria must be used for patient selection to achieve durable success with endovascular aortic aneurysm repair (EVAR). The goal of this study was to assess morphologic suitability (MS) of abdominal aortic aneurysms (AAAs) for 2 currently approved bifurcated stent grafts and identify reasons for exclusion from EVAR. The authors reviewed the electronic charts of 1,795 consecutive patients who were diagnosed as having AAA between January 1999 and July 2001 at their institution. Three hundred and twenty patients had an AAA with a diameter of > or = 5.0 cm, measured on computed tomography (CT). The records of 301 patients, 254 men, 47 women, with a mean age of 74 years were available for review, and these patients constituted the study cohort. Criteria used for MS included a proximal neck length > or = 15 mm; neck diameter between 18 and 26 mm; neck angulation < or = 60 degrees ; common or external iliac artery (CIA or EIA) diameters of 7-16 mm and 8-13 mm, respectively, for AneuRx (Medtronic Ave, Santa Rosa, CA) and Ancure (Guidant Cardiac and Vascular Division, Menlo Park, CA) bifurcated grafts. AAAs were suitable for AneuRx device in 14% of patients (43 of 301; 95% CI = 11-19%) and for Ancure in 5% (16 of 301; 95% CI = 3.1-9%). The main reason for exclusion was an inadequate proximal aortic neck (73%). The neck was too short in 49.5%, too wide in 64% and badly angulated in 12% of the patients. Iliac artery morphology precluded EVAR with AneuRx and Ancure devices in 52% and 80%. Both CIAs were too wide for EVAR in 43% and 77%, respectively. When iliac artery diameter < or = 20 mm was accepted, iliac suitability for AneuRx increased from 49% to 70% and overall suitability increased from 14% to 20%. When more permissive criteria were used for MS (neck length > or = 10 mm, neck diameter < or = 30 mm, CIA < or = 20), 39% of patients became candidates for EVAR. More than three fourths of the patients with an AAA > or = 5.0 cm in size, seen in a tertiary referral center, are morphologically not suitable for EVAR using 2 currently approved bifurcated endografts. The main reasons for exclusion are a short or wide proximal aortic neck. Considerable changes in size of the devices and in proximal attachment techniques have to occur before most AAAs will be suitable for EVAR.

Endovascular aneurysm repair with the Ovation TriVascular Stent Graft System utilizing a predominantly percutaneous approach under local anaesthesia

“…6 Continuous evolution and improved redesigning of AAA endografts allows for the inclusion of more complex anatomies in EVAR's indications. [7][8][9][10][11] The Ovation Abdominal Stent Graft System (TriVascular Inc., Santa Rosa, CA) is a modular endograft designed for the treatment of AAAs. It is a new device intended to overcome the limitations of currently available stent grafts and to accommodate a broader range of anatomy by addressing the two most important issues in EVAR: access and seal.…”

Abdominal Aortic Aneurysms: Changing Paradigms in Treatment

“…All devices have guidelines for use under the Food and Drug Administration (FDA) which where created to assist the clinician in determining anatomical acceptability of the device to ensure the optimal outcome. In the past there has been a 20-60% reported suitability following the information for use guidelines (IFU) 6,7 however with advancing technology the delivery systems for these devices have gotten smaller, with hydrophilic coats and the devices themselves have become larger with different configurations which has greatly expanded the anatomic criteria for the use of these devices. Devices used outside of the FDA-IFU guidelines have been associated with increased complication rates and adherence to these guidelines as much as possible is recommended.…”

Chimney Technique in the Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysm

“…Exclusion of the aneurysm relies on obtaining a mechanical seal proximal and distal to the aneurysm. A signi fi cant proportion of patients, 20-50 % in some series, are not candidates for EVAR based on their anatomy [ 3 ] . Of those excluded based on anatomical considerations, up to half are excluded because of insuf fi cient aneurysm neck length to achieve a seal proximally.…”