title: Clinical outcomes for hostile versus favorable aortic neck anatomy in endovascular aortic aneurysm repair using modular devices.
abstract: BACKGROUND
  Endovascular aneurysm repair (EVAR) is not generally recommended for patients with hostile neck anatomy. This study analyzed the clinical implications of various clinical features of proximal aortic neck anatomy.
  
  
  METHODS
  Prospectively collected data from 258 EVAR patients using modular devices were analyzed. Patients were classified as having favorable neck anatomy (FNA) or hostile neck anatomy (HNA). HNA was defined as any or all of length of <10 mm, angle of >60°, diameter of >28 mm, ≥50% circumferential thrombus, ≥50% calcified neck, and reverse taper. Univariate, multivariate, and Kaplan-Meier analyses were used to compare early and late clinical outcomes.
  
  
  RESULTS
  FNA was present in 37% and HNA was present in 63%. Clinical and demographic characteristics were comparable. Technical success was 99%. Mean follow-up was 22 months (range, 1-78 months). Perioperative complication rates were 3% for FNA vs 16% for HNA (P = .0027). Perioperative deaths were 0% for FNA and 3% for HNA (P = .2997). Proximal type I early endoleaks (intraoperative) occurred in 9% of FNA vs 22% for HNA (P = .0202). Intraoperative proximal aortic cuffs were used to seal endoleaks in 9% of FNA vs 22% of HNA (P = .0093). At late follow-up, abdominal aortic aneurysm expansion was noted in 6% of FNA vs 7% of HNA (P = .8509). Rates of freedom from late type I endoleaks at 1, 2, 3, and 4 years were 97%, 97%, 97%, and 90% for FNA vs 89%, 89%, 89%, and 89% for HNA (P = .1224); rates for late interventions were 95%, 90%, 90%, and 90% for FNA vs 95%, 93%, 91%, and 85% for HNA (P = .6902). Graft patency at 1, 2, and 3 years was 99%, 99%, and 99% for FNA vs 97%, 92%, and 90% for HNA (P = .0925). The survival rates were 93%, 84%, 76%, and 76% for FNA vs 88%, 82%, 74%, and 66% for HNA (P = .2631). Reverse taper was a significant predictor for early type I endoleak (odds ratio [OR], 5.25, P < .0001), reverse taper (OR, 5.95; P < .0001) and neck length (OR, 4.15; P = .0146) were for aortic cuff use; circumferential thrombus (OR, 2.44; P = .0448), and neck angle (OR, 3.38; P = .009) were for perioperative complications.
  
  
  CONCLUSIONS
  Patients with HNA can be treated with EVAR, but with higher rates of early (intraoperative) type I endoleak and intervention. The midterm outcomes are similar to FNA.
authors.affiliation: Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV 25304, USA. ali.aburahma@camc.org
authors.forename: Ali F
authors.initials: AF
authors.lastname: Aburahma
authors.forename: John E
authors.initials: JE
authors.lastname: Campbell
authors.forename: Albeir Y
authors.initials: AY
authors.lastname: Mousa
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Hass
authors.forename: Patrick A
authors.initials: PA
authors.lastname: Stone
authors.forename: Akhilesh
authors.initials: A
authors.lastname: Jain
authors.forename: Aravinda
authors.initials: A
authors.lastname: Nanjundappa
authors.forename: L Scott
authors.initials: LS
authors.lastname: Dean
authors.forename: Tammi
authors.initials: T
authors.lastname: Keiffer
authors.forename: Joseph
authors.initials: J
authors.lastname: Habib
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / 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; D016009:Chi-Square Distribution; D057867:Endoleak / Q000209:etiology / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011474:Prosthesis Design; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D015996:Survival Rate; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014903:West Virginia