Outcomes over Time in Patients with Hostile Neck Anatomy Undergoing Endovascular Repair of Abdominal Aortic Aneurysm

Summary 

This article evaluated outcomes of early (2004-2008) and late (2019-2013) period patients with hostile neck anatomy who underwent endovascular aneurysm repair (EVAR). Hostile neck parameters were at least one of the following: 1) Neck length ≤ 10 mm 2) Focal bulge in the neck (> 3 mm) 3) > 2-mm reverse taper within 1 cm below the renal arteries 4) Neck thrombus or calcification > 50% of the circumference 5) Angulation ≥ 60% below within 3 cm the renal arteries. The study compared 61 of 216 (28%) patients in the early period and 64 of 144 (44%) patients in the late period. No significant differences were observed in hostile neck anatomic factors between the early and late periods in this study. However, abdominal aortic aneurysm sac regression in the late period was better as compared to the early period (late period, 73.5% vs early period, 55.7%; P = 0.038). Another notable observation was; type 1a endoleaks in patients in the late group with suprarenal fixation was higher as compared to patients with infrarenal fixation (suprarenal, 27.0% vs infrarenal, 7.9%; P = 0.025). Otherwise, there were no significant differences observed in periprocedural factors and outcome measures over time in patients with hostile neck who underwent EVAR.

Commentary

This article evaluates differences in outcomes in an early and late period EVAR experience in patients with hostile neck anatomy. Early post-EVAR era, hostile aortic neck used to be an open surgical indication. A large number of patients (up to 40%) would not be suitable for standard EVAR treatment due to anatomic challenges, mainly hostile neck of the aorta. However, as we gained more experience in time, we felt more comfortable to use devices out of their label to use. Noticeably there is very limited data on this topic. This paper (Bryce et al) studied this important topic and correlated early and late experience with suprarenal and infrarenal fixation. It turns out infrarenal is better than suprarenal fixation in terms of type 1a endoleak. Aneurysm sac regression was better in later group. Strikingly, the paper found no significant difference between earlier and later experience even though later group has more anatomically challenging patient group. This is probably linked to gaining more procedural experience and more and better EVAR products commercially available. There are several other methods available such as fenestrated EVAR (FEVAR) especially for elective cases, or “chimney/snorkel” (brachial access) or a periscope (femoral access) techniques especially for emergent/urgent cases. Thanks to the authors for providing suprarenal vs infrarenal fixation outcomes with historical differences for hostile aortic neck EVAR. This is an exciting and challenging topic, more outcome studies needed with other techniques as well.

Click here for abstract

Bryce Y, Kim W, Katzen B, Benenati J, Samuels S. Outcomes over Time in Patients with Hostile Neck Anatomy Undergoing Endovascular Repair of Abdominal Aortic Aneurysm. J Vasc Interv Radiol. 2018 Jul;29(7):1011-1016.

Post Author:
Ulku Cenk Turba, M.D. FSIR
Professor of Radiology
Director, Interventional Radiology Residency, and Fellowship
Rush University Medical Center
@cturba