title: Does hostile neck anatomy preclude successful endovascular aortic aneurysm repair?
abstract: OBJECTIVE
  Poor outcomes have been reported with endovascular aneurysm repair (EVAR) in patients with hostile neck anatomy. Unsupported endografts with active fixation may offer certain advantages in this situation. We compared EVAR results using the Ancure (Guidant) endograft in patients with and without hostile neck anatomy.
  
  
  METHODS
  Records of EVAR patients from October 1999 to July 2002 at a tertiary care hospital were retrospectively reviewed from a division database. Patients with elective open abdominal aortic aneurysm (AAA) repair during the same period were reviewed to determine those unsuitable for EVAR. Hostile neck anatomy, assessed by computer tomography (CT) scans and angiograms, was defined as one or more of the following: (1) neck length </=10 mm, (2) focal bulge in the neck >3 mm, (3) >2-mm reverse taper within 1 cm below the renal arteries, (4) neck thrombus > or =50% of circumference, and (5) angulation > or =60 degrees within 3 cm below renals.
  
  
  RESULTS
  Three hundred and twenty-two patients underwent EVAR with an average follow-up of 18 months. Patients in Phase II trials (n = 41), repaired with other graft types (n = 48), or without complete anatomic records (n = 27) were excluded. Demographics and co-morbidities were similar in the 115 good-neck (GN) and 91 bad-neck (BN) patients except for age (mean, 72.9 years GN vs 75.7 BN; P = 0.13), gender (11% female GN vs 22% BN; P =.04); neck length (mean, 21.8 mm GN vs 14.4 mm BN: P <.001), and angulation (mean, 22 degrees GN vs 40 degrees BN; (P <.001). Perioperative mortality (0 GN vs 1.1% BN), late mortality (5.2% GN vs 4.4% BN), all endoleaks (19.1% GN vs 17.6% BN), proximal endoleaks (0.8% GN vs 2.1% BN), and graft migration (0 for both groups) did not reach statistical significance. Neck anatomy precluded EVAR in 106 of 165 (64%) patients with open AAA.
  
  
  CONCLUSIONS
  Unsupported endografts with active fixation can yield excellent results in treating many medically compromised patients with hostile neck anatomy. Nonetheless, an unsuitable neck remains the most frequent cause for open abdominal AAA.
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
authors.forename: Ellen D
authors.initials: ED
authors.lastname: Dillavou
authors.forename: Satish C
authors.initials: SC
authors.lastname: Muluk
authors.forename: Robert Y
authors.initials: RY
authors.lastname: Rhee
authors.forename: Edith
authors.initials: E
authors.lastname: Tzeng
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Woody
authors.forename: Navyash
authors.initials: N
authors.lastname: Gupta
authors.forename: Michel S
authors.initials: MS
authors.lastname: Makaroun
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001012:Aorta, Abdominal / Q000000981:diagnostic imaging / Q000473:pathology*; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D000075202:Contraindications; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012077:Renal Artery / Q000000981:diagnostic imaging / Q000473:pathology; D012189:Retrospective Studies; D015607:Stents