title: Treatment of Hostile Proximal Necks During Endovascular Aneurysm Repair.
abstract: Endovascular aneurysm repair (EVAR) is a therapy that continues to evolve rapidly as advances in technology are incorporated into new generations of devices and surgical practice. Although EVAR has emerged as a safe and effective treatment for patients with favorable anatomy, treatment of patients with unfavorable anatomy remains controversial and is still an off-label indication for endovascular treatment with some current stent-grafts. The proximal neck of the aneurysm remains the most hostile anatomic barrier to successful endovascular repair with long-term durability. Open surgery for unfavorable necks is still considered the gold standard treatment in contemporary practice, despite the increased mortality and morbidity attributed to suprarenal cross-clamping, particularly in high-risk patients. Evolving technology may overcome the obstacles preventing endovascular treatment of unfavorable proximal neck anatomy; current approaches include purely endovascular as well as hybrid approaches, and generally include strategies that either extend the length of the short neck, move the proximal neck more proximally, or keep the short neck intact. These approaches include the use of debranching techniques, banding, chimneys, fenestrated and branched devices, filling the sac with endobags, endoanchors, and other novel devices. These newer-generation devices appear to have promising short- and midterm results. However, lack of good evidence of efficacy with long-term results for these newer approaches still precludes wide dissemination of endovascular solutions for the hostile proximal neck.
authors.affiliation: Federal University of Minas Gerais, Panamerican Circulation Institute, Belo Horizonte, Minas Gerais, Brazil;
authors.forename: Tulio Pinho
authors.initials: TP
authors.lastname: Navarro
authors.affiliation: Madre Teresa Hospital Aortic Center, Panamerican Circulation Institute, Belo Horizonte, Minas Gerais, Brazil; and.
authors.forename: Rodrigo de Castro
authors.initials: Rde C
authors.lastname: Bernardes
authors.affiliation: Federal University of Minas Gerais, Panamerican Circulation Institute, Belo Horizonte, Minas Gerais, Brazil;
authors.forename: Ricardo Jayme
authors.initials: RJ
authors.lastname: Procopio
authors.affiliation: Federal University of Minas Gerais, Panamerican Circulation Institute, Belo Horizonte, Minas Gerais, Brazil;
authors.forename: Jose Oyama
authors.initials: JO
authors.lastname: Leite
authors.affiliation: Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Alan
authors.initials: A
authors.lastname: Dardik
keywords: Aneurysm; Angulated neck; EVAR; Hostile neck; Short neck