Advertisement

Maybe Neck Dilation Matters after All?

  • Juliet Blakeslee-Carter
    Affiliations
    Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
    Search for articles by this author
  • Adam W. Beck
    Correspondence
    Corresponding author. Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham (UAB), Birmingham, AL, USA.
    Affiliations
    Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
    Search for articles by this author
Open ArchivePublished:January 09, 2021DOI:https://doi.org/10.1016/j.ejvs.2020.12.011
      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.
      • Oliveira N.F.G.
      • Oliveira-Pinto J.
      • van Rijn M.J.
      • Baart S.
      • Ten Raa S.
      • Hoeks S.E.
      • et al.
      Risk factors, dynamics and clinical consequences of aortic neck dilatation after standard EVAR.
      Importantly, these authors demonstrated that AND was more common than reported by previous smaller series,
      • Diehm N.
      • Dick F.
      • Katzen B.T.
      • Schmidli J.
      • Kalka C.
      • Baumgartner I.
      Aortic neck dilatation after endovascular abdominal aortic aneurysm repair: a word of caution.
      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.
      • Diehm N.
      • Dick F.
      • Katzen B.T.
      • Schmidli J.
      • Kalka C.
      • Baumgartner I.
      Aortic neck dilatation after endovascular abdominal aortic aneurysm repair: a word of caution.
      ,
      • Qaderi S.M.
      • Tran N.T.
      • Tatum B.
      • Blankensteijn J.D.
      • Singh N.
      • Starnes B.W.
      Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair.
      Risk factors for AND identified in this study mirror findings from previous publications,
      • Qaderi S.M.
      • Tran N.T.
      • Tatum B.
      • Blankensteijn J.D.
      • Singh N.
      • Starnes B.W.
      Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair.
      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.
      • Qaderi S.M.
      • Tran N.T.
      • Tatum B.
      • Blankensteijn J.D.
      • Singh N.
      • Starnes B.W.
      Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair.
      ,
      • Monahan T.S.
      • Chuter T.A.M.
      • Reilly L.M.
      • Rapp J.H.
      • Hiramoto J.S.
      Long-term follow-up of neck expansion after endovascular aortic aneurysm repair.
      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.
      • Patel R.
      • Powell J.T.
      • Sweeting M.J.
      • Epstein D.M.
      • Barrett J.K.
      • Greenhalgh R.M.
      The UK endovascular aneurysm repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis.
      This work also highlights the importance of appropriate pre-operative decision making in relation to device longevity and patient life expectancy.

      References

        • Oliveira N.F.G.
        • Oliveira-Pinto J.
        • van Rijn M.J.
        • Baart S.
        • Ten Raa S.
        • Hoeks S.E.
        • et al.
        Risk factors, dynamics and clinical consequences of aortic neck dilatation after standard EVAR.
        Eur J Vasc Endovasc Surg. 2021; 62: 26-35
        • Diehm N.
        • Dick F.
        • Katzen B.T.
        • Schmidli J.
        • Kalka C.
        • Baumgartner I.
        Aortic neck dilatation after endovascular abdominal aortic aneurysm repair: a word of caution.
        J Vasc Surg. 2008; 47: 886-892
        • Qaderi S.M.
        • Tran N.T.
        • Tatum B.
        • Blankensteijn J.D.
        • Singh N.
        • Starnes B.W.
        Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair.
        J Vasc Surg. 2019; 69: 1059-1065
        • Monahan T.S.
        • Chuter T.A.M.
        • Reilly L.M.
        • Rapp J.H.
        • Hiramoto J.S.
        Long-term follow-up of neck expansion after endovascular aortic aneurysm repair.
        J Vasc Surg. 2010; 52: 303-307
        • Patel R.
        • Powell J.T.
        • Sweeting M.J.
        • Epstein D.M.
        • Barrett J.K.
        • Greenhalgh R.M.
        The UK endovascular aneurysm repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis.
        Health Technol Assess. 2018; 22: 1-132

      Linked Article

      Comments

      Commenting Guidelines

      To submit a comment for a journal article, please use the space above and note the following:

      • We will review submitted comments as soon as possible, striving for within two business days.
      • This forum is intended for constructive dialogue. Comments that are commercial or promotional in nature, pertain to specific medical cases, are not relevant to the article for which they have been submitted, or are otherwise inappropriate will not be posted.
      • We require that commenters identify themselves with names and affiliations.
      • Comments must be in compliance with our Terms & Conditions.
      • Comments are not peer-reviewed.