Introduction: Hostile anatomic characteristics in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) may lead to technical nonsuccess of the procedure, late complications, reintervention or death. The authors analyzed anatomical abdominal aortic aneurysm specific considerations so as technical endoprosthesis implantation and correlate them with endoleak development and postoperative survival.
Methods: Authors retrospectively reviewed all consecutive, elective, EVAR's that occurred between 2010 and 2016, with available data, at one institution for abdominal, infra renal, aortic aneurysms. The patients comorbidities were registered and preoperative CT scan was analyzed considering the proximal zone (diameter, length, presence of thrombus or calcification), the distal zone (length and diameter), aortic aneurysm (maximum diameter, angulation, axis deviation, mural thrombus and patency of the inferior mesenteric artery and the lumbar arteries) and concomitant iliac aneurysm or peripheral occlusive disease. Outcomes were endoleak development and death.
Results: We analyzed 56 patients, 54 (96%) male with a medium age of 78 (min 61, max 89) years. During a medium 3,4 years of follow up, 12 (21%) patients developed endoleak (10 type II and 2 type I) and 18 (32%) died. The adjusted analysis showed a statistically significant association between aneurysm angulation (p=0,046), patency of the inferior mesenteric artery and the lumbar arteries (p=0,044) and aneurysm diameter (p=0,009) with endoleak development. Notice that 40% of the aneurysms that impaired a significant axis deviation developed endoleak. All except one endoleak were diagnosed within the first year after EVAR. None of the deaths that occurred during the follow up period were correlated to post intervention aneurysm enlargement or rupture. However we found a statistically significant association between patency of the inferior mesenteric artery and the lumbar arteries (p=0,042) and early death during the first year after EVAR.
Conclusion: Even though many aneurysm are suitable for EVAR, unfavorable aneurysm morphologic characteristics and predictable complicated endograft placement should be taken into consideration. For such clinical cases, a surgical approach should be considered. We believe that current recommendations for follow up with angioCT only at 1 and 12 months during the first year following EVAR is a good practice conduction since most of endoleaks developed during these period. If neither endoleak nor aneurysm enlargement is documented during first year after EVAR, colour duplex ultrasonography is a good alternative for annual postoperative surveillance.