title: The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts.
abstract: OBJECTIVE
  To compare the outcome of endovascular aneurysm repair (EVAR) versus conventional open repair (OR) in patients with a short, angulated or otherwise challenging proximal neck.
  
  
  METHODS
  The definition of a challenging proximal neck was based on diameter (>or=28 mm), length (<or=15 mm), angulation (>or=60 degrees ), shape (reverse tapered or bulging), and thrombus lining (>50%). Between January 2005 and December 2007, 187 consecutive patients (159 men; mean age 73 years, range 48-92) operated for asymptomatic abdominal aortic aneurysm (AAA) were identified as having challenging proximal neck morphology. Of these, 61 patients were treated with OR at center I (group A), 71 with standard EVAR (group B; 45 center I, 29 center II) and 52 with fenestrated EVAR (group C) at center II. Clinical examination and computed tomography were performed at 1 month and yearly thereafter.
  
  
  RESULTS
  There was no statistically significant difference between groups A, B, and C regarding primary technical success rate, 30-day mortality, or late AAA-related mortality. The mean length of follow-up was 19.5 months (range 0-40). Freedom from reintervention at 3 years was 91.8%, 79.7%, and 82.7% for groups A, B, and C, respectively (p = 0.042). The only statistically significant difference between standard and fenestrated EVAR was a higher incidence of late sac expansion [9 (12.2%) versus 1 (1.9%), p = 0.036] in the standard stent-graft group. Reinterventions were more frequent after EVAR (p = NS), but open reinterventions were more common after OR. Reinterventions after EVAR were related to the presence of an angulated (p = 0.039) or short neck (p = 0.024).
  
  
  CONCLUSIONS
  The results of EVAR and OR were similar for AAAs with a challenging proximal neck. Endovascular reinterventions were more frequent after EVAR, particularly in patients with an angulated or short neck. Open reinterventions were more common after OR. More patients and long-term data are needed to confirm these findings.
authors.affiliation: Vascular and Endovascular Surgery Unit, University of Siena, Italy. e.chisci@gmail.com
authors.forename: Emiliano
authors.initials: E
authors.lastname: Chisci
authors.forename: Thorarinn
authors.initials: T
authors.lastname: Kristmundsson
authors.forename: Gianmarco
authors.initials: G
authors.lastname: de Donato
authors.forename: Timothy
authors.initials: T
authors.lastname: Resch
authors.forename: Francesco
authors.initials: F
authors.lastname: Setacci
authors.forename: Björn
authors.initials: B
authors.lastname: Sonesson
authors.forename: Carlo
authors.initials: C
authors.lastname: Setacci
authors.forename: Martin
authors.initials: M
authors.lastname: Malina
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D015607:Stents; D013548:Sweden; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome