Reducing complications by better case selection: Anatomic considerations
Section snippets
Proximal anatomy
Complete hemodynamic sealing at the proximal endograft attachment site and secure endograft fixation are absolute requirements for complete aneurysm exclusion.4 Anatomic characteristics of the proximal aortic neck influence both the effectiveness of aneurysm exclusion and the durability of attachment.6 Failure of proper attachment and sealing at the proximal neck predisposes toward complete technical failure, resulting in a proximal attachment-site leak and/or distal migration. Inadequate
Distal aortic neck anatomy
Specific information regarding length, diameter, and characteristics of the distal aortic neck were probably more important when endografts in an aorto-aortic tube configuration were used. Currently, tube stent-grafts have all but been abandoned in favor of bifurcated, or aorto-uni-iliac, devices when necessary. However, the nature of the distal aorta still plays a role in selection criteria and outcomes. Some patients have an extremely narrow distal aortic lumen, which is often the result of
Iliac anatomy
Iliac artery anatomy probably represents the greatest anatomical influence on short-term morbidity following EVAR.4 Iliac artery morphology is essential to obtaining delivery device access into the aorta, sealing the aneurysm to prevent distal attachment-site endoleaks, and maintaining adequate perfusion to the pelvis.4, 6 Critically important factors related to iliac artery anatomy include tortuosity, intraluminal diameter, calcification, and presence of iliac artery aneurysmal disease. In
Do smaller aneurysms have better results with EVAR?
At the author’s institution, an unexpected finding in our analysis of the contribution of anatomic factors to poor outcome following EVAR was the apparent effect of preoperative AAA diameter.2 Multivariate analysis revealed both the preoperative maximum aneurysm diameter and the proximal neck length to be independent predictors of attachment-site leak, despite the interrelationship of these factors. Specifically, in AAAs less than 5 cm in diameter, the incidence of all endoleaks was 8.3%,
Conclusion
In conclusion, although proper anatomic selection is critical in obtaining good outcomes following endovascular aneurysm repair, it is difficult to define strict inclusion criteria to an absolute degree. Although generally accepted guidelines certainly exist, the vascular surgeon must use excellent judgment to realize a compromise between extremely rigorous inclusion criteria that would exclude a large number of patients, and being too willing to tolerate unacceptable anatomy, which would
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Predictors of Five-Year Survival after EVAR: 10-Year Experience of Single-Center Cohort Study
2023, Annals of Vascular SurgeryTechnical Success and Long-Term Results with Excluder/C3 Endoprosthesis in Narrow Aortic Bifurcations: First Italian Multicentre Experience
2018, Annals of Vascular SurgeryCitation Excerpt :These features, now considered essential for the patient's eligibility to EVAR, are widely described in international literature17,18 and refer principally to the following issues: proximal aortic neck region, aortic tortuosity index, presence and patency of aortic branch vessels, iliac artery anatomy, degree of calcification and thrombosis at the device's landing points, and hypogastric arteries patency. Moreover, several predictive factors for EVAR failure have been clearly recognized and studied, as there is great evidence that poor anatomic patient selection based on these criteria would imply greater risk for procedure-related complications and poor long-term outcomes.6 Strong correlation was found between specific anatomic features outside of these criteria and technical failures such as attachment-site EL,7,19 endograft migration,20 and even limb occlusion.21,22
Anatomic and clinical characterization of the narrow distal aorta and implications after endovascular aneurysm repair
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