Prognostic significance of large diameter proximal aortic neck in endovascular aneurysm repair

Abstract

Summary. Background: Adverse morphological features of the proximal aortic neck have been identified as culprits for late failure after endovascular aneurysm repair (EVAR). Our objective was to investigate the prognostic role of wide proximal aortic neck in EVAR. Methods: We conducted a review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies comparing outcomes of EVAR in patients with large versus small proximal aortic neck. A meta-analysis of time-to-event data was performed with the inverse-variance method and the results were reported as summary hazard ratio (HR) and 95 % CI. We applied random-effects models of meta-analysis. Results: We identified 9 observational studies reporting on a total of 7,682 patients (1,961 with large diameter and 5,721 with small diameter neck). The hazard of death (HR 1.57, 95 % CI 1.23–2.01; P = 0.0003), aneurysm-related reintervention (HR 2.06, 95 % CI 1.23–3.45; P = 0.006), type Ia endoleak (HR 6.69, 95 % CI 4.39–10.20; P < 0.001), sac expansion (HR 10.07, 95 % CI 1.80–56.53; P = 0.009), aneurysm rupture (HR 2.96, 95 % CI 2.00–4.38; P < 0.0001), and neck-related adverse events (HR 10.33, 95 % CI 4.95–21.56; P < 0.0001) was higher in patients with large diameter proximal aortic neck than in those with small neck. Conclusions: Patients with a large proximal aortic neck were found to have poorer outcomes than those with small neck. This finding has implications in decision making when selecting methods for aneurysm treatment and in EVAR surveillance for aneurysm-related complications in this cohort of patients.

Pre-operative Aortic Neck Characteristics and Post-operative Sealing Zone as Predictors of Type 1a Endoleak and Migration After Endovascular Aneurysm Repair: A Systematic Review and Meta-Analysis

“…These findings are consistent with previous systematic reviews that focused on individual neck characteristics. The higher odds for developing type 1a endoleak in patients with a larger neck diameter were also reported in systematic reviews by Antoniou et al 6 and Kouvelos et al 7 The current results regarding neck angulation were also consistent with findings by Qayyum et al 9 Although neck length is one of the most important neck characteristics for pre-operative planning, 4,11 this variable has not been described much in the literature. An explanation for this could be that patients with a short proximal neck length are almost exclusively treated with open surgical repair or complex (fenestrated, branched, or chimney) EVAR.…”

Shortest Apposition Length at the First Postoperative Computed Tomography Angiography Identifies Patients at Risk for Developing a Late Type Ia Endoleak After Endovascular Aneurysm Repair

“…This finding broadly supports other studies associating large neck diameter with delayed T1aEL, increased risk of rupture, and lower overall survival rate. 20 As a result of this, the nominal endograft diameter was significantly larger in the T1aEL group as well. Nowadays, more complex EVAR procedures, like FEVAR or BEVAR, should be considered in patients who otherwise need an endograft with a nominal diameter of >30mm, to achieve sufficient seal in the infrarenal neck.…”

The impact of large proximal aortic neck on endovascular aneurysm repair outcomes

“…[8] Howard et al [4] reported that patients with a large proximal aortic neck had a higher rate of type 1a endoleaks and a lower five-year survival rate. In another study, Antoniou et al [17] compiled the results of nine studies that included 7,682 patients with AAAs, grouped as patients with large versus small aortic necks. The risk of death, aneurysm-related reintervention, type 1a endoleak, sac enlargement and aneurysm rupture were significantly higher in patients with a large proximal aortic neck than those with a small neck.…”