4 Fixation Seal Morphology of AAA Neck Length Length Diameter Diameter AngulationSuprarenal vs infrarenal fixationSealLengthDiameterAngulationCalcificationThrombus
5 Morphology of AAA Neck Diameter Axial vs. orthogonal (3D) slices Outer wall vs. inner wall vs. mid-wallTrue wall (CT) vs. patent lumen diameter (angio)Measure at least 5-mm intervals (minimum number of measurements = 3)Determine neck morphology (shape)Straight, conical, funnel, hourglass, barrel
8 Morphology & Sizing 20º angle Circumference = 81.2 mm (instead of 78.5 mm)Circle:2πR = 81.2 mmR = 12.9 mmDiameter: 25.8 mm
9 Morphology & Sizing X 20º angle Stentgraft Oversize = 20 16 % AORTAOversize = %XR=12,9 mm
10 Definitions of hostile neck anatomy 1.Short neck—a distance of less than or equal to 10 mm (diameter:26 mm)2.Neck bulge—a focal enlargement of the aneurysm neck of at least 3 mm within the first 15 mm after the most caudal renal artery3.Reverse taper—gradual neck dilation of greater than or equal to 2 mm within the first 10 mm after the most caudal renal arteryEllen D. Dillavou, et allJ Vasc Surg 2003;38:
11 Definitions of hostile neck anatomy 4.Angulated neck—aortic angle of at least 60 degrees within the first 30 mm after the most caudal renal artery5.Significant neck thrombus— thrombus covering more than 50% of the circumference of the aortic diameter in the proximal neck.Ellen D. Dillavou, et allJ Vasc Surg 2003;38:
18 1.Alterations in neck composition HOSTILE NECK OF INFRARENAL AAA1.Alterations in neck composition(such as the presence of thrombus or calcification)2. Neck angulation > 6003. Undesirable neck length< 10mm4. Diameter > 32 mm
20 > 600Neck Length < 15mmData from the EUROSTAR registry were used to assess outcomes for patients with short infrarenal necks. Patients were categorized into one of three groups according to the neck length:> 15 mm, 11 to 15 mm, and ≤ 10 mm.The rate of type IA endoleaks was significantly greater for patients with neck lengths ≤ 10 mm (11%).At follow-up, freedom from type I endoleak was 97% in those with > 15 mm necks, but only 90% in those with 11- to 15-mm necks, and 89% in those with ≤ 10-mm necks.
22 J Vasc Surg 2011;54:609-1511. vanMarrewijkCJ,LeursLJ,VallabhaneniSR,HarrisPL,ButhJ,LaheijRJ, et al. Risk-adjusted outcome analysis of endovascular abdominal aortic aneurysm repair in a large population: how do stent-grafts com- pare? J Endovasc Ther 2005;12:12. DeBruinJL,BaasAF,ButhJ,PrinssenM,VerhoevenEL,CuypersPW, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010;362:13. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:14. Espinosa G, Ribeiro M, Riguetti C, Caramalho MF, Mendes WD, Santos SR. Six-year experience with talent stent-graft repair of abdom- inal aortic aneurysms. J Endovasc Ther 2005;12:35-45.15. Greenberg RK, O’Neill S, Walker E, Haddad F, Lyden SP, Svensson LG, et al. Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2 thoracic grafts: intermediate-term results. J Vasc Surg 2005;41:
23 EVAR Deployment in Anatomically Challenging Necks Outside the IFU J.T. Lee *, B.W. Ullery, C.K. Zarins, C. Olcott, IV, E.J. Harris, Jr., R.L. DalmanDivision of Vascular Surgery, Stanford University Medical Center, Stanford, CA, USA2013 European Society for Vascular Surgery.Methods: A total of 218 patients (197 men, 21 women) at a single academic center underwent endovascular aneurysm repair (EVAR) with a commercially available device between January 2004 and December Available medical records, pre- and postoperative imaging, and clinical follow-up were retrospectively reviewed. Patients were divided into those with suitable anatomy (instructions for use, IFU) for EVAR and those with high- risk anatomic aneurysm characteristics (non-IFU).Results:There were no early or late surgical conversions. Rates of migration, endoleak, need for reintervention, sac regression, and freedom from aneurysm-related death were similar between the groups (p > .05).Conclusions: EVAR may be performed safely in high-risk patients with unfavorable neck anatomy using particular commercially available endografts. In our experience, the preferential use of active suprarenal fixation and aggressive use of proximal cuffs is associated with optimal results in these settings. Mid-term outcomes are comparable with those achieved in patients with suitable anatomy using a similar range of EVAR devices. Careful and mandatory long-term follow-up will be necessary to confirm the benefit of treating these high-risk anatomic patients.
24 From the Society for Clinical Vascular Surgery Does hostile neck anatomy preclude successful endovascular aortic aneurysm repair?Ellen D. Dillavou, MD, Satish C. Muluk, MD, Robert Y. Rhee, MD, Edith Tzeng, MD, Jonathan D. Woody, MD, Navyash Gupta, MD, and Michel S. Makaroun, MD, Pittsburgh, PaVasc Surg 2003;38:CONCLUSIONNeck anatomy is the major determinant for suitability of patients for endovascular repair.With careful selection, many patients with classic “hostile necks” can be successfully repaired using an unsupported unibody endograft with active proximal fixation. Despite good success with an ever-increasing number of patients, hostile neck anatomy remains the predominant reason that patients are denied EVAR.
29 Endurant endograft is also a highly conformable device that is equipped with an enhanced fixation mechanism, which has been found to be advantageous in the treatment of severely angulated proximal neck
30 One-year multicenter results of 100 abdominal aortic aneurysm patients treated with the Endurant stent graftJasper W. van Keulen, MD,a,b,….MD,b Frans L. Moll, MD, PhD,a Hence J. Verhagen, MD, PhD,b and Joost A. van Herwaarden, MD, PhD,a Utrecht, Nieuwegein, and Rotterdam, The NetherlandsJ Vasc Surg 2011;54:Proximal neck length of 33 +/- 14 mm (9 to 82 mm), and an infrarenal angulation of 44 +/- 25° (0°-108°).Nineteen of the 100 included patients had at least one anatomic characteristic that was considered a violation of the instructions for use (IFU) of the Endurant stent graft.Conclusion: The treatment of patients with AAAs with the Endurant stent graft seems to be successful and durable during the first year after EVAR. Despite the wider inclusion criteria for the Endurant, and with 19% of our patients treated outside the IFU, the AAA-related mortality, number of type I or III endoleaks, and reintervention rates are comparable to the results of other stent grafts.
31 ?One-year multicenter results of 100 abdominal aortic aneurysm patients treated with the Endurant stent graftJasper W. van Keulen, MD,a,b,….MD,b Frans L. Moll, MD, PhD,a Hence J. Verhagen, MD, PhD,b and Joost A. van Herwaarden, MD, PhD,a Utrecht, Nieuwegein, and Rotterdam, The NetherlandsJ Vasc Surg 2011;54:
32 One-year multicenter results of 100 abdominal aortic aneurysm patients treated with the Endurant stent graftJasper W. van Keulen, MD,a,b,….MD,b Frans L. Moll, MD, PhD,a Hence J. Verhagen, MD, PhD,b and Joost A. van Herwaarden, MD, PhD,a Utrecht, Nieuwegein, and Rotterdam, The NetherlandsJ Vasc Surg 2011;54:
33 Proximal Seal in Angulated Proximal Necks The Aorfix endograft (Lombard Medical Technologies PLC, Oxfordshire, UK) received US Food and Drug Administration approval in 2013 for the treatment of angulated necks (up to 90°)Weale et al: 30 patients with morechallenging proximal neck anatomies ( mean infrarenal angle, 81.2°; range, 63°–110°).After a follow-up of 6 months, two cases (6.7%) of primary proximal type I endoleaks were found to persist despite intraoperative ballooning of the proximal stent..WealeAR,BalasubramaniamK,MacierewiczJ,etal.OutcomeandsafetyofAorfixstentgraftinhighlyangulatedneck-a prospectiveobservationalstudy(arbiter2). EurJVascEndovascSurg.2011;41:
43 Current Endograft Options Proximal Design Characteristics: Of the current commercially available endograft designs, the Medtronic Endurant endograft was specifically designed to treat many of these hostile neck condition1. Suprarenal stents with hooks provide high level active fixation for migration resistance2. One piece laser cut stent with anchoring pins designed for better structural integrity and durability.3. Lower amplitude stent provides better sealing with short necks4. M-shaped stents provide high conformability5. Engineered and tested to treat 1cm necks at up to 60° neck angulation
50 CONCLUSIONSInsufficient high-level evidence exists to demonstrate safe use of standard EVAR in patients with hostile neck anatomy.From the present analysis, it may be concluded that EVAR should be used cautiously in patients with unfa-vorable aneurysm neck anatomy.EVAR should be applied only in patients with high surgical risk in whom all other alternative endovascular treatments, such as fenestrated repair, are not feasible.