Suprarenal Endograft Fixation Avoids Adverse Outcomes Associated with Aortic Neck Angulation

The advent of endovascular therapy has had a profound impact on repair of abdominal aortic aneurysms (AAA). Prudent patient selection, particularly in regard to unfavorable anatomy, is emerging as perhaps the most important determinant of endovascular abdominal aortic aneurysm repair (EVAR) outcome. The aim of this study was to examine the association of one such anatomic factor, proximal aortic neck angulation, with the incidence of adverse events following EVAR. Prospectively collected data on 289 EVAR repairs with the Talent endograft (Medtronic, Inc., Minneapolis, MN) from March 1998 to June 2000 were analyzed. Stent graft–specific adverse events studied were migration, endoleak, kinking, thrombosis, and AAA expansion. Computed tomography (CT) scanning with three-dimensional post-processing and/or aortography was used to measure aortic neck angle. Patients were categorized into one of four groups according to their neck angle: I (0-10°); II (11-39°); III (40-59°); or IV (60-85°). Outcomes were evaluated by chi-squared analysis and ANOVA. There was a direct correlation between AAA diameter and neck angle (p = 0.002). There was no difference in endoleak rate (p = 0.877), stent migration (p = 0.850), or AAA expansion rate (p = 0.599) between groups. Device kinking >45° was associated with neck angulation ≥60° (p = 0.013), but not with other adverse outcomes. The average neck angle was 30° in patients with endoleaks and 31° in patients without endoleaks. Increasing aortic neck angulation was not associated with the selected adverse outcomes within 1 year following EVAR with the Talent stent graft using suprarenal fixation with the exception of graft kinking. This may be related to the graft design that permits suprarenal aortic fixatiou of the proximal stent graft, Whether severe degrees of angulation of 60° or greater can be safely treated with suprarenal fixation requires further study.