title: Outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile neck anatomy.
abstract: OBJECTIVE
  The principal anatomic contraindication to endovascular aneurysm repair (EVR) is an unfavorable proximal aortic neck. With increasing experience, a greater proportion of patients with unfavorable neck anatomy are being offered EVR. This study aimed to evaluate outcomes in patients with challenging proximal aortic neck anatomy.
  
  
  METHODS
  Prospectively collected data from 147 consecutive patients who underwent EVR between December 1997 and April 2005 were supplemented with a retrospective review of medical records and radiological images. Unfavorable anatomic features were defined as neck diameter >28 mm, angulation >60 degrees, circumferential thrombus >50%, and length <10 mm. Eighty-seven patients with 0 adverse features (good necks) were compared with 60 patients with one or more adverse features (hostile necks).
  
  
  RESULTS
  Comparing the good neck with the hostile neck group, there were no significant differences in the incidence of primary technical success (p = 0.15), intraoperative adjunctive procedures (p = 0.22), early proximal type I endoleak (<30 days) (p = 1.0), late proximal type I endoleak (>30 days) (p = 0.57), distal type I endoleak (p = 0.40), type III endoleak (p = 0.51), secondary interventions (p = 1.0), aneurysm sac expansion (p = 0.44), or 30 day mortality (p = 0.70). The good neck group had a significantly increased incidence of type II endoleak (p = 0.023). By multivariate analysis, the incidence of intraoperative adjunctive procedures was significantly increased in the presence of severe angulation (p = 0.041, OR 3.08, 95% CI 1.05-9.04).
  
  
  CONCLUSIONS
  Patients with severely hostile proximal aortic neck anatomy may be treated with EVR, although severely angulated necks require additional intraoperative procedures. Early outcomes are encouraging and suggest that indications for EVR may be expanded to include patients with hostile neck anatomy.
authors.affiliation: Vascular Institute, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK.
authors.forename: Edward
authors.initials: E
authors.lastname: Choke
authors.forename: Graham
authors.initials: G
authors.lastname: Munneke
authors.forename: Robert
authors.initials: R
authors.lastname: Morgan
authors.forename: Anna-Maria
authors.initials: AM
authors.lastname: Belli
authors.forename: Ian
authors.initials: I
authors.lastname: Loftus
authors.forename: Robert
authors.initials: R
authors.lastname: McFarland
authors.forename: Thomas
authors.initials: T
authors.lastname: Loosemore
authors.forename: Matthew M
authors.initials: MM
authors.lastname: Thompson
mesh_terms: D000368:Aged; D001012:Aorta, Abdominal / Q000000981:diagnostic imaging / Q000473:pathology*; D017544:Aortic Aneurysm, Abdominal / Q000473:pathology* / Q000601:surgery*; D001027:Aortography; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008499:Medical Records; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology / Q000473:pathology; D011446:Prospective Studies; D011474:Prosthesis Design; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015607:Stents / Q000145:classification; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome