Original title: Outcomes of Endovascular Aneurysm Repair in Patients with Hostile Neck Anatomy Reference: Stather et al. European Journal of Vascular and Endovascular Surgery 44 (2012) 556-561.

Endovascular treatment of abdominal aortic aneurysms (EVAR) has already shown benefits in terms of mortality compared with conventional surgery. 

The disadvantages of EVAR are reinterventions for endoleaks, migration or device failure and these could be related to an unfavorable anatomy. 

The objective of this study was to compare the results in EVAR patients with a favorable neck versus an unfavorable neck, which is defined as one with at least one of the following characteristics: diameter greater than 28 mm, angle> 60 ° , length

The study included 552 consecutive patients receiving EVAR between January 1999 and July 2010 at one hospital with an average follow-up of 4.1 years. Of the total number of patients, 199 (36.1%) had an unfavorable neck. There were no differences in baseline characteristics between the groups. The devices used were: Cook Zenith, Medtronic Talent/Endurant and Gore Excluder. At follow-up after 30 days there was no difference between groups in procedural failure (CF 0,6% vs. CD 2%; p=0,12), mortality (CF 1,1% vs. CD 0,5%; p=0,45), endoleak type 1 (CF 0,8% vs. CD 2,5%; p=0,12) or reoperation (CF 2,8% vs. CD 5%; p=0,12).

In longer term follow-up, (average 4 years), we observed a higher incidence of endoleak type I in unfavorable neck (4.5% vs. 9.5%, P = 0.02) but, conversely, increased incidence of endoleak in favorable necks (16.7% vs. 10.6%, p <0.05). There were no group differences in device migration (2.5% versus CF. CD 3%, P = 0.75), expansion of the bag (CF 13% vs. CD 9.5%; p=0.22), aneurysm rupture (CF 1,1% vs. CD 3.5%; p=0,05) or mortality (CF 15.1% vs. CD 14.6%; p=0,86). The difference was significant in the number of reoperations for patients with an unfavorable neck (CF 11% vs. CD 22.8%; p<0.01).

Conclusion 

Patients with abdominal aortic aneurysm and an unfavorable neck can be treated as endovascular with equally long-term mortality as favorable neck patients but with a higher incidence of endoleak type I and reintervention.

Editorial Comment:

The larger serial with longer follow up published by EVAR with an unfavorable neck shows the feasibility and safety of the procedure but also the need for careful monitoring in the long term. While unfavorable necks had a higher incidence of reoperations, these were mostly to treat leaks type I B and type II, which hardly relate to the anatomy of the neck. One limitation of the study is that it was conducted in a single center which takes away external validity and this is no minor fact when facing a challenging anatomy where experience must play a fundamental role.

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