Durability and long term success of endovascular aneurysm repair (EVAR) depends upon achieving and maintaining an appropriate proximal seal and fixation within the infrarenal aortic neck. Aortic neck dilation (AND) has been well documented in the existing literature and has been suggested as a potential source of critical EVAR failure through endoleaks and stent migration. Although other reports have suggested that AND occurs generally without clinical consequence, here, Oliveira et al. report that AND does in fact have an important relationship with EVAR failure in longer follow up in their large single centre experience.
1
Importantly, these authors demonstrated that AND was more common than reported by previous smaller series,
2
and occurred in the vast majority of cases, which may be explained by better long term follow up. Similar to prior studies, while AND was found to occur most frequently during the first year, it remained present and ongoing throughout the lifetime of surveillance, in the majority of patients. Despite that finding, prior reports are relatively reassuring that AND occurs without clinical significance.2
,3
Risk factors for AND identified in this study mirror findings from previous publications,
3
and also found an association with graft oversizing. The role of oversizing in development of AND is difficult to define with confidence from this report, but the association should certainly give operators pause for thought during stent graft selection. These results are limited by the wide variation in oversizing within the sample (13%–28% oversizing) and potential bias introduced through measurement techniques, device selection and patient substrate related to the quality and diameter of the infrarenal neck. Despite these limitations, this relationship remains concerning, and should certainly be explored further.Unique to this study was the identified relationship between AND and both development of Type 1a endoleaks and stent graft migration. These relationships have intuitively always made sense, and perhaps had not previously been demonstrated simply due to smaller sample sizes and limited follow up.
3
,4
Although there are conflicting reports in the literature, AND has been well demonstrated to be a frequent occurrence after EVAR and, at least in this report, increases the rate of important adverse events that can cause late treatment failure. Whether AND is caused by the stent graft design and/or oversizing and truly leads to failure or is simply related to poor patient selection and use of infrarenal EVAR in patients destined to fail therapy, remains not completely clear.
In any case, these findings support the critical role played by rigorous long term follow up after EVAR, which has certainly been emphasised in the existing literature.
5
This work also highlights the importance of appropriate pre-operative decision making in relation to device longevity and patient life expectancy.References
- Risk factors, dynamics and clinical consequences of aortic neck dilatation after standard EVAR.Eur J Vasc Endovasc Surg. 2021; 62: 26-35
- Aortic neck dilatation after endovascular abdominal aortic aneurysm repair: a word of caution.J Vasc Surg. 2008; 47: 886-892
- Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair.J Vasc Surg. 2019; 69: 1059-1065
- Long-term follow-up of neck expansion after endovascular aortic aneurysm repair.J Vasc Surg. 2010; 52: 303-307
- The UK endovascular aneurysm repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis.Health Technol Assess. 2018; 22: 1-132
Article info
Publication history
Published online: January 09, 2021
Accepted:
December 14,
2020
Received:
November 27,
2020
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© 2020 European Society for Vascular Surgery. Published by Elsevier B.V.
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- Editor's Choice – A Comparison of Computed Tomography Angiography and Colour Duplex Ultrasound Surveillance Post Infrarenal Endovascular Aortic Aneurysm Repair: Financial Implications and Impact of Different International Surveillance GuidelinesEuropean Journal of Vascular and Endovascular SurgeryVol. 62Issue 2
- PreviewUse of colour duplex ultrasound (CDUS) and computed tomography angiography (CTA) for infrarenal endovascular aortic aneurysm repair (EVAR) surveillance differs in internationally published guidelines. This study aimed firstly to compare CDUS detection of significant sac abnormalities with CTA. Secondly, a sensitivity analysis was conducted to compare financial estimates of the, predominantly CDUS based, local and Society of Vascular Surgery (SVS) protocols, the risk stratified European Society of Vascular Surgery (ESVS) protocol, and the CTA based National Institute of Health and Care Excellence (NICE) protocol.
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- Risk Factors, Dynamics, and Clinical Consequences of Aortic Neck Dilatation after Standard Endovascular Aneurysm RepairEuropean Journal of Vascular and Endovascular SurgeryVol. 62Issue 1
- PreviewAortic neck dilatation (AND) occurs after endovascular aneurysm repair (EVAR) with self expanding stent grafts (SESs). Whether it continues, ultimately exceeding the endograft diameter leading to abdominal aortic aneurysm (AAA) rupture, remains uncertain. Dynamics, risk factors, and clinical relevance of AND were investigated after EVAR with standard SESs.
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- Aortic Neck Dilatation Following EVAR: Looking for a Needle in a HaystackEuropean Journal of Vascular and Endovascular SurgeryVol. 62Issue 1
- PreviewKey to the long term success of an endovascular aneurysm repair (EVAR) is a durable proximal sealing zone. In their paper, Oliveira et al. provide a comprehensive investigation of aortic neck dilatation (AND) in a large single centre cohort of patients, who underwent standard infrarenal EVAR with self expanding stent grafts (SESs) over a 15 year period.1 While continued AND potentially poses a significant risk to this long term durability, there remain many unanswered questions, particularly in the context of SES.
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