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Combining different device components during EVAR: A technique to achieve fixation and seal in high risk hostile aortic neck anatomies
Dimitris Virvilis, MD, Robert J. Meissner, MD, George J. Koullias, MD, Apostolos Tassiopoulos, MD.
SUNY Stony Brook University Hospital, Stony Brook, NY, USA.
Objective: EVAR has become the preferred technique over open repair in a large majority of patients with abdominal aortic aneurysms. Endograft migration and type I endoleak, are two serious late complications associated with this procedure. Short length and large diameter necks, excessive aortic neck angulation, conical, reverse conical or barrel shaped neck, and neck thrombus or calcification are risk factors. These factors, increase the incidence of ineffective proximal fixation and/or seal.
The objective of this study is to describe our experience in using a technique that utilizes specific design advantages of two different approved EVAR systems to prevent distal migration and type 1 endoleak in patients with unfavorable neck characteristics.
Methods: We reviewed four cases that underwent composite endografting using anatomic fixation and super-renal fixation. We defined challenging aortic neck anatomy as wide diameter aortic neck, excessive angulation (range of >70 degrees with or without double angulation), very short aortic necks (<7mm) with conical, reverse conical or barrel neck shape, and thrombus or calcification (>50% of circumference). In all cases a composite technique was used: anatomic fixation at the aortoiliac biburcation with the Powerlink® endograft mainbody (Endologix®) and proximal supra-renal fixation of the aortic neck with the Endurant® (Medtronic®) proximal extension cuffs. All patients were followed with post-operative CTA at 1, 3, and 6 months.
Results: Mean neck diameter was 24(22-32)mm, neck length 5(2-7.5) mm and neck angulation 69.5(58-89) degrees. Two necks were barrel shaped, one conical and one reverse conical. Neck calcification was present in 100% and neck thrombus (as defined above) in 50% (2/4) cases. Follow-up ranged from 6-16 months. No evidence of Type 1 endoleak was identified on CTA. Sac diameter decreased from 7.46cm to 6.23 cm (17%) during the follow up period. No distal endograft migration was encountered.
Conclusions: This technique is aiming to prevent late complications such as graft migration and endoleaks for patients with challenging aortic neck anatomy. It combines anatomical fixation at the aortoiliac bifurcation with additional suprarenal fixation with a high radial strength device. More cases and further follow up is required to validate the mid and long term durability of this technique.
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