Standard endovascular aneurysm repair in patients with wide infrarenal aneurysm necks is associated with increased risk of adverse events

Abstract

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 toward a more intensive surveillance following EVAR in these patients in the long term.

Editor's Choice – Influence of Proximal Aortic Neck Diameter on Durability of Aneurysm Sealing and Overall Survival in Patients Undergoing Endovascular Aneurysm Repair. Real World Data from the Gore Global Registry for Endovascular Aortic Treatment (GREAT)

“…All previous studies investigating aortic neck diameter have used larger cut offs, such as using 36 mm diameter stent grafts. 23,24 These cases represent a very small minority of patients undergoing EVAR in the real world (only 177/3166 [5.6%] of patients in GREAT had aortic neck diameters 30 mm) which leads to limited study numbers, reduced power for useful analysis, and limited overall clinical relevance. Several key findings should be mentioned.…”

Comparative study of clinical outcome of endovascular aortic aneurysms repair in large diameter aortic necks (>31 mm) versus smaller necks

“…Usually, neck dilation after EVAR is a well-documented phenomenon, especially when one uses oversized self-expanding endografts. 24 Cao et al 27 found significant proximal aortic neck dilation in 30% of patients, whereas Gargiulo et al 26 found significant enlargement of the infrarenal neck in 41% of patients. Dilation can occur owing to the chronic outward radial force of the endograft on the infrarenal neck.…”

“…Other studies have found unfavorable results with treatment of large infrarenal aortic neck diameters with endovascular devices. 24 Oliveria et al 24 found an increased risk of type IA and III endoleaks, neck-related secondary interventions, and proximal neck-related adverse events in 74 patients with a neck diameter 30 mm or greater. In 2011, Schanzer et al 25 analyzed 10,228 patients undergoing EVAR between 1999 and 2008 and found that patients with large neck diameters (≥28 mm) had an increased risk of secondary sac enlargement.…”

“…The infrarenal neck has been shown to be histologically diseased, which may lead to progressive dilation. 24 Immune pathways are upregulated within the nondilated aorta proximal to the aneurysmal segment, and these areas have demonstrated histologic signs of destruction. 32 An increased aneurysmal burden demonstrated by the presence of larger aortic neck diameters and AAA size has been shown to be an independent risk factor for continuing aortic neck dilation.…”

A systematic review of standardized methods for assessment of endograft sealing on computed tomography angiography post-endovascular aortic repair, and its influence on endograft-associated complications

“…We therefore propose to modify the previous risk-stratified surveillance protocol, because patients with increased risk may benefit from a timely second postoperative CTA scan. These high-risk patients include those with challenging pre-operative anatomy, such as short neck length (<10 mm), large neck diameter (>30 mm), large aortic curvature (>50 m −1 ), large aneurysm sac diameter (>65 mm), or large CIA diameter (>19 mm) [21][22][23][24][25][26], those treated outside indications for use [27], those with any endoleak or insufficient proximal or distal seal (<10 mm) on the first postoperative CTA [4,5], and those where suspicion of complications arises during follow-up, such as >5 mm aneurysm growth. In these patients, a second postoperative CTA is advised within 2 years, on which endograft apposition and position should be re-assessed and compared with the baseline values on the first postoperative CTA scan to allow detection of continuous (subtle) deterioration of apposition over time.…”