title: Challenging neck anatomy is associated with need for intraoperative endovascular adjuncts during endovascular aortic aneurysm repair (EVAR).
abstract: BACKGROUND
  The purpose of this study was to determine which proximal seal zone characteristics were predictive of early and late type Ia endoleak development after endovascular aortic aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysmal disease.
  
  
  METHODS
  We evaluated 146 patients who underwent EVAR between January 2006 and March 2007. In the cohort, high-resolution computed tomography images of 100 (68.5%) patients were available, which showed detailed measurement of proximal neck parameters, including diameter, length, calcification, thrombus, suprarenal and infrarenal angles, and reverse taper morphology. Postprocessing of digital data sets was performed to obtain centerline-of-flow measurements. Relevant medical records and follow-up computed tomography scans were reviewed.
  
  
  RESULTS
  Mean age of the patients was 72.7 years, with 78% being male. Of these patients, 66% did not satisfy the instructions for use for the Zenith EVAR device, and 50% did not satisfy the instructions for use for the AneuRx device. Nine patients had intraoperative type Ia endoleaks. A 100% assisted primary technical success rate was achieved with the adjunctive use of angioplasty (n = 4), uncovered stent (n = 3), and extension cuff (n = 2) placement. There was a significant association between type Ia endoleak development and magnitude of the infrarenal angle (p < 0.01); however, other parameters were not significant. At follow-up (mean, 587 days), no patient had a type Ia endoleak, and there were no aneurysm-related deaths.
  
  
  CONCLUSIONS
  Our data indicate that infrarenal angle is related to intraoperative type Ia endoleak occurrence, but other factors often thought to be indicative of adverse neck anatomy are not significant predictors. Moreover, all type Ia endoleaks in this cohort were successfully eliminated intraoperatively, and durability was confirmed on postoperative surveillance. These data demonstrate that challenging neck anatomy is associated with the need for intraoperative endovascular adjuncts, and that effective and durable aneurysm exclusion should still be expected.
authors.affiliation: Department of Surgery, Division of Vascular Surgery, Allegheny General Hospital, Pittsburgh, PA 15212, USA. grisafijl@yahoo.com
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Grisafi
authors.forename: Rodeen
authors.initials: R
authors.lastname: Rahbar
authors.forename: Justin
authors.initials: J
authors.lastname: Nelms
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Detschelt
authors.forename: Bart A
authors.initials: BA
authors.lastname: Chess
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Benckart
authors.forename: Satish C
authors.initials: SC
authors.lastname: Muluk
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D016009:Chi-Square Distribution; D057867:Endoleak / Q000209:etiology / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D010414:Pennsylvania; D011474:Prosthesis Design; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome