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A Journal on Vascular and Endovascular Surgery
Italian Journal of Vascular and Endovascular Surgery 2011 June;18(2):65-71
Endovascular therapy of AAA with proximal angulated neck: comparing alternative treatments
Villani A., Baiocchi G., Di Nardo W., Franceschini E., Gianfelice F., Giansante A., Moretti V.
Operative Unit of Vascular Surgery, “G. Mazzini” Civil Hospital, Teramo, Italy
Aim. The severe angulation of the abdominal aortic aneurysms (AAA) proximal neck represents a high risk factor of failure in the endovascular treatment. It increases the difficulties in deploying and delivering the device with the consequent high risk of type 1 endoleak. On the other hand many of the patients may present several risk factors in open surgery. In case selected therapeutic alternatives may be considered.
Methods. In our medical centre 220 AAA patients were treated with endovascular therapy from January 2000 to March 2009. Six of them with AAA diameter >6 cm were considered high risk patients for surgery due to the problematic comorbidities they presented such as proximal neck angulation >60°. In four cases patients presented an italic S-shaped neck, with the first curve at 90° at the infrarenal level, then horizontal and a second distal curve in the proximal aneurysm. Endovascular treatment has been chosen for three patients (group I) with complex morphology and unfavorable anatomy of the proximal neck. A Gore Tag thoracic endoprosthesis in association with an Excluder aortic bisiliac endoprosthesis has been used. In fact the former, which is extremely flexible and adaptable to the wide aortic angulation, has been anchored to the proximal neck in order to reconstruct a “new neck” within the aneurysm where the other endoprosthesis could be easily deployed. Then three patients ( group II) presented tortuous, calcified and small iliac arteries which were recognized as important risk factors for successful tag use. Therefore an Endurant endoprosthesis has been used for the extreme flexibility . It has a suprarenal stent with anchoring pins, an m-shaped infrarenal stent for short necks (10 mm) with 75° angulation and a low profile delivering system with hydrophilic coating that improves the deployment of endoprosthesis also in presence of unfavourable anatomy of iliac arteries.
Results. Technical success of the procedure has been achieved in all patients. No type I leak has been recorded in both groups in the first one year trial, but only one type II leak without any important increasing of the aneurysm diameter.
Conclusion. EVAR is contraindicated in some cases with the high angulation of the proximal neck and its anatomy in AAA as well as with tortuous, calcified small iliac arteries. When open surgery is not tolerated and AAA is widely dilated the choice of therapy is not obvious. The experiences describe a comparison of two different endovascular therapeutic procedures which may help the treatment of high risk patients with AAA anatomy unfavourable for EVAR, if used after an accurate study of the anatomy.