STANDARD EVAR IN LARGE NECKS — IS IT A REASONABLE SOLUTION?
Introduction: Endovascular aneurysm repair (EVAR) has expanded into progressively more challenging anatomies. Proximal neck-morphology represents the major determinant of EVAR durability. Neck-diameter constitutes one of the most important anatomical neck features and influence proximal sealing over time.
The purpose of this study is to investigate the influence of wide proximal necks on outcome after standard EVAR.
Methods: MEDLINE databases were searched to identify publications addressing the relation between aortic neck diameter and incidence of AAA-related complications.
Results: Six studies were included in our review, addressing 6602 patients: 1616 with large necks and 4986 with small necks. Five studies, including 6446 patients, reported higher rates of type 1A endoleak in patients with large necks with hazard/ odds ratios ranging between 2.3–4.1. One study found a higher risk of post-implant rupture in patients with necks>30mm (HR: 5.1; 95% CI, 1.4–19.2). Four studies reported on the influence of wide necks on AAA-related mortality without finding any association. Reduced overall survival was seen in patients with large necks in 4 studies (long term survival ranged between 61.6 and 68% for wide neck patients and 75–90 % for small neck patients), mostly attributable to cardiovascular causes.
Conclusions: Patients with wide proximal necks are at greater risk for type 1A endoleak, post-implant rupture and overall-mor- tality. This subgroup of patients may be considered for more complex proximal seal strategies with fenestrated/branched devices or open repair, although there is no evidence of superiority of alternative strategies to standard EVAR in large necks.
This subgroup should be offered more stringent imaging follow-up and aggressive treatment of medical comorbidities.
2. Patel R, Sweeting MJ, Powell JT, Greenhalgh RM. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet (London, England) 2016;388:2366-74.
3. Nordon IM, Karthikesalingam A, Hinchliffe RJ, Holt PJ, Loftus IM, Thompson MM. Secondary interventions following endovascular aneurysm repair (EVAR) and the enduring value of graft surveil- lance. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2010;39:547-54.
4. Stather PW, Sayers RD, Cheah A, Wild JB, Bown MJ, Choke E. Outcomes of endovascular aneurysm repair in patients with hostile neck anatomy. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2012;44:556-61.
5. Ingle H, Fishwick G, Thompson MM, Bell PR. Endovascular repair of wide neck AAA--preliminary report on feasibility and complications. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2002;24:123-7.
6. Bastos Goncalves F, Hoeks SE, Teijink JA, et al. Risk factors for proximal neck complications after endovascular aneurysm repair using the endurant stentgraft. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2015;49:156-62.
7. SchanzerA,GreenbergRK,HeveloneN,etal.Predictorsofabdominal aortic aneurysm sac enlargement after endovascular repair. Circulation 2011;123:2848-55.
8. Oliveira NFG, Bastos Goncalves FM, Van Rijn MJ, et al. Standard endo- vascular aneurysm repair in patients with wide infrarenal aneurysm necks is associated with increased risk of adverse events. J Vasc Surg 2017;65:1608-16.
9. AbuRahma AF, DerDerian T, AbuRahma ZT, et al. Comparative study of clinical outcome of endovascular aortic aneurysms repair in large diameter aortic necks (>31 mm) versus smaller necks. J Vasc Surg 2018;68:1345-53.e1.
10. Oliveira NFG, Goncalves FB, Ultee K, et al. Patients with large neck diameter have a higher risk of type IA endoleaks and aneurysm rupture after standard endovascular aneurysm repair. J Vasc Surg 2019;69:783-91.
11. Kaladji A, Steintmetz E, Goueffic Y, Bartoli M, Cardon A. Long-Term Results of Large Stent Grafts to Treat Abdominal Aortic Aneurysms. Annals of vascular surgery 2015;29:1416-25.
12. Jim J, Rubin BG, Geraghty PJ, Criado FJ, Fajardo A, Sanchez LA. A 5-year comparison of EVAR for large and small aortic necks. J Endovasc Ther 2010;17:575-84.
13. Howard DPJ, Marron CD, Sideso E, Puckridge PJ, Verhoeven ELG, Spark JI. 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). European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2018;56:189-99.
14. Tadros RO, Faries PL, Ellozy SH, et al. The impact of stent graft evolu- tion on the results of endovascular abdominal aortic aneurysm repair. J Vasc Surg 2014;59:1518-27.
15. Brewster DC, Jones JE, Chung TK, et al. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Annals of surgery 2006;244:426-38.
16. Broos PP, Stokmans RA, van Sterkenburg SM, et al. Performance of the Endurant stent graft in challenging anatomy. J Vasc Surg 2015;62:312-8.
17. Aburahma AF, Campbell JE, Mousa AY, et al. Clinical outcomes for hostile versus favorable aortic neck anatomy in endovascular aortic aneurysm repair using modular devices. J Vasc Surg 2011;54:13-21.
18. McFarland G, Tran K, Virgin-Downey W, et al. Infrarenal endovas- cular aneurysm repair with large device (34- to 36-mm) diameters is associated with higher risk of proximal fixation failure. J Vasc Surg 2019;69:385-93.
19. Oliveira NFG, Ultee K, van Rijn MJ, et al. Anatomic predictors for late mortality after standard endovascular aneurysm repair. J Vasc Surg 2019;69:1444-51.
20. Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management. Annals of surgery 1984;199:223-33.
21. Ohrlander T, Dencker M, Dias NV, Gottsater A, Acosta S. Cardio- vascular predictors for long-term mortality after EVAR for AAA. Vascular medicine (London, England) 2011;16:422-7.
22. Kouvelos GN, Antoniou G, Spanos K, Giannoukas A, Matsagkas M. Endovascular aneurysm repair in patients with a wide proximal aortic neck: a systematic review and meta-analysis of comparative studies. The Journal of cardiovascular surgery 2019;60:167-74.