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Morphology And Outcomes Of Endovascular Repair Of Ruptured Abdominal Aortic Aneurysms With Hostile Neck Anatomy
Grayson S. Pitcher, MD
1,
Benjamin C. Ford, MD1, Doran Mix, MD
1, Karina S. Newhall, MD
1, Indrani Sen, MBBS
2, Michael C. Stoner, MD
1, Bernardo C. Mendes, MD
3.
1University of Rochester, Rochester, NY, USA,
2Mayo Clinic Health System, Eau Claire, WI, USA,
3Mayo Clinic, Rochester, MN, USA.
Objective Ruptured abdominal aortic aneurysms (rAAAs) have a high rate of hostile neck anatomy (HNA). This study evaluated the risk factors associated with intra-operative type Ia endoleak (T1EL) in endovascular repair (EVAR) for rAAAs with HNA and determined the association of intra-operative T1EL with long-term survival.
Methods A multi-center retrospective review was performed to identify patients with rAAAs and HNA between 2004 and 2021. HNA was defined as infrarenal aortic neck diameter >28 mm, infrarenal neck length <15 mm and angulation >60 degrees. Clinical characteristics and morphology were reviewed for predictors of intra-operative T1EL. The Kaplan-Meier method was used to estimate survival.
Results 85 patients underwent standard EVAR for rAAAs with HNA. Mean age was 74.6 ± 10.3 years and 74% were male. 24 (28%) patients required adjunctive procedures for an intra-operative T1EL. Large aneurysm size (OR 1.027, CI 1.004-1.050,
P = .02), increased distance from the renal arteries to the aortic bifurcation (OR 1.020, CI 1.000-1.040,
P = .04) and lower thrombus burden (OR .567, CI .335-.958,
P = .03) were associated with intra-operative T1EL and the need for adjunctive procedures on univariate analysis. Overall survival for patients who underwent standard EVAR at 30-days, 1-year and 5-years was 84%, 74% and 64%, respectively. There was no difference in 30-day (84% vs. 83%,
P = .99), 1-year (75% vs. 71%,
P = .73) (Figure) or 5-year survival (67% vs. 54%,
P = .34) in patients without an intra-operative T1EL versus patients with a T1EL who required an adjunctive procedure. There was no difference in 1-year (98% vs. 96%,
P = .48) or 5-year (85% vs. 92%,
P = .51) aortic-related reintervention. No specific morphologic features were predictive of aortic-related re-intervention at 5 years.
ConclusionDespite a high rate of adjunctive intra-operative procedures for T1EL in patients who underwent EVAR for rAAAs with HNA, there was no difference in survival or aortic-related reintervention at 30-days, 1- and 5-years. Larger aneurysms, increased renal artery to aortic bifurcation distance, and decreased thrombus burden were risk factors for intra-operative T1EL.
Figure. Kaplan-Meier analysis of all-cause mortality at 1-year in patients with and without a T1EL.
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