Aortic Neck Issues Associated Clinical Sequelae/Implications for Graft Choice Eric Verhoeven, MD, PhD, A. Katsargyris, MD Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
Disclosures William Cook Europe/Cook Inc. Consultant & Research grants W.L. Gore & Associates Consultant & Research grants Atrium Consultant Siemens Consultant Endologix Consultant
Case 1: Failed 2xFEVAR F372
Partial opening of graft
Case 2: 4xFEVAR 61 YO Male AAA 65mm EVAR 4 yrs ago
Plan 4x FEVAR Easy CT and SMA Adequate sealing zone Proximal extension still possible
Case 3: 3xFEVAR 65 YO Male Juxtarenal AAA Dmax: 53 mm Saccular Co-morbidity CAD PAD 01.03.1952
Proximal Neck?? Proximal neck length: 0 or 40 mm?
3x FEVAR Plan
Postop CTA
Case 5: 3xFEVAR (wrong choice) 71 YO Male 2011 Juxtarenal AAA Dmax: 54 mm Co-morbidity CAD 01.01.1940
Proximal Neck Proximal neck length: 4-5mm, conical
Problem: Dilated Thoracic Aorta Dmax above Celiac trunk: 36-37mm
Plan 36-37mm 3x FEVAR
3x FEVAR
Postop CTA 36mm
CTA @ 1 year 39 mm
CTA @ 2 years 41mm
CTA @ 4 years 44 mm
CTA @ 6 years 45 mm
Treatment Plan Redo F/BEVAR 1x Branch for CA 3x Fenestrations
Infrarenal Aortic Neck Dilates after open Surgery
Conflicting- Controversial Data
Proximal neck at all? AAA growth from 5.5 to 8cm
AND after EVAR Meta-analysis Inclusion criteria 1. To report AND after EVAR 2. To include at least 5 patients 3. To provided data on AND quantification Kouvelos et a, J Endovasc Ther 2017
AND after EVAR 26 articles published between 1998 and 2015 9721 patients Kouvelos et a, J Endovasc Ther 2017
Incidence of aortic neck dilatation 12 studies 8550 pts 24.6% of the patients (95% CI 18.6% to 31.8%)
Clinical outcome during FU 7 studies 1759 pts endoleak type I, migration, reintervention 26% 2%
High-risk for AND Graft oversizing Small/Large size proximal neck Type of endograft (Sx vs Bx)
Aortic Neck Enlargement after EVAS (BES) and EVAR (SES) vs. Savlovskis et al. J Vasc Surg 2015;62:541-9
AND Not Associated with EVAS Savlovskis et al. J Vasc Surg 2015;62:541-9
Aortic Neck Stability after Polymer Sealing with Ovation 161 patients Mean follow-up 32mo (24-50) CT scans with 2yr follow-up for 89 cases Three zones (A, B, C) examined separately Morphological comparison between preoperative and postoperative images De Donato et al. J Vasc Surg 2016;63(1):8 15
Aortic Neck Stability after Polymer Sealing with Ovation No AND after a minimum 2 year follow-up 0.1 mm (0,-0.3) 0.18 ± 0.22mm 0.0 mm (0,-0.6mm) -0.32 ± 0.87mm 0.0 mm (+0.4,- 0.3mm) -0.06 ± 0.97mm De Donato et al. J Vasc Surg 2016;63(1):8 15
Aortic Neck Stability after Polymer Sealing with Ovation Core lab results demonstrate stable neck diameter and durable seal with Ovation through 5 years Open Repair 2 Ovation Pivotal Trial data as of August 2, 2016 Self- Expanding Stents 1 Ovation System 3 1 Monahan JVS 2010: 52: 303-7. N=46. Devices: Cook Zenith / 2 Rodway EJVES 2008;35:685-93 EVAR: N=67, Open N=56 3 Ovation Global Pivotal Trial. N=94. Data as of Aug 2, 2016
Wide Infrarenal Neck Wide infrarenal neck seems to be associated with worse outcome
Mean increase 11% for the lowest renal 3% to 5% at the level of the renal arteries <3% for the SMA and CT 12% type I endoleak
EVAR in Wide Infrarenal Necks The evolution of aortic neck dilatation (AND) may lead to the loss of an adequate proximal seal. Seventy-four patients (17.3%) with a neck diameter of >30 mm were compared with a control group of 353 patients. standard EVAR with an Endurant stent graft Median follow-up 3.1 years Oliveira et al, J Vasc Surg 2017
EVAR in Wide Infrarenal Necks
Discussion Literature Definition & Quality of Proximal Neck (Length) Degree of oversizing? AND and BE Stents Seem to treat the neck better. Why better than open repair?