Aortic Neck Attachment Failure and the AneuRx Graft: Incidence, Treatment Options, and Early Results

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Some investigators have reported that proximal attachment failure is a long-term complication of endovascular abdominal aortic aneurysm repair (EVAR) with the AneuRx (Medtronic, Santa Rosa, CA) device. We evaluated the need for an intervention in patients with suboptimai proximal fixation as well as the feasibility and early success of a variety of treatment strategies. From October 1999 to October 2003, we performed 365 EVARs using the AneuRx graft. At a mean follow-up of 23.7 ± 14.8 months, 20 patients (5.5%) with suboptimal outcomes (14 with a type I endoleak, one with a type III endoleak, and 5 with an inadequate seal zone <1 cm) were considered for treatment. Characteristics of each patient's aortic neck anatomy that could be associated with proximal attachment failure were evaluated. Eighteen patients (90%) underwent successful treatment (9 AneuRx cuffs, 6 Talent cuffs, 5 aortic stents, one redo endograft, and two surgical conversions) without major perioperative complications, one patient had a persistent type I endoleak despite endovascular treatment, and one patient refused treatment, ultimately leading to aneurysm rupture. There have been no further endoleaks or graft migrations noted since the secondary intervention at a mean follow-up of 13.9 ± 11.8 months. In our experience, proximal attachment failure associated with the AneuRx graft is relatively uncommon and usually associated with unfavorable neck anatomy. Despite this, most cases are treatable by endovascular means. Long-term follow-up is needed to assess the ultimate frequency of these combined device reconstructions.

Section snippets

INTRODUCTION

Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) has become an increasingly accepted treatment alternative for selected patients with infrarenal AAAs since the 1999 approval of the AneuRx (Medtronic, Santa Rosa, CA) and Ancure (Guidant, Santa Clara, CA) devices. The AneuRx device is currently the most frequently used endovascular graft in the United States, with over 34,000 implants since approval and more than 38,000 patients worldwide. The 5-year mid-term follow-up data on the U.S.

Patient Selection

All patients undergoing endovascular aortoiliac aneurysm repair at our institution are prospectively entered in a database for long-term follow-up and comparison of their outcomes. Between October 1999 and October 2003, 620 patients underwent EVAR at our institution using a variety of approved and investigational devices. During that period, 365 patients underwent EVAR using the AneuRx device. These patients and their associated data were reviewed under a Health Insurance Portability and

RESULTS

Eighteen of the 20 patients who developed proximal attachment failure were successfully treated at a mean follow-up of 23.7 ± 14,8 months from the date of the original graft implantation. These patients were treated with AneuRx aortic cuff (n = 9), Talent aortic cuff (n = 6), Palmaz stent (n = 5), Excluder aortic cuff (n = 1), or surgical conversion (n = 2), Some patients required multiple procedures, or multiple modalities were used at the time of the intervention for endovascular graft

DISCUSSION

The reported 5-year clinical results for the U.S. AneuRx trial include 97.2% freedom from allcause rupture, 91.1% freedom from surgical conversion, and 96.8% freedom from aneurysm-related death.1 These outstanding results were obtained despite the limited experience of many physicians and the learning curve associated with using endovascular devices. Since the start of that trial in 1996, we have gained significant knowledge of the behavior of the device and endovascular techniques in general.

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Presented at the Spring Meeting of the Peripheral Vascular Surgery Society, Anaheim, CA, June 5, 2004.

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