Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks

Objective The aim of this study was to evaluate midterm clinical and morphologic outcomes after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) with large (≥28 mm) infrarenal neck. Methods From 2009 to 2012, we prospectively collected and retrospectively analyzed clinical, morphologic, and intraoperative and postoperative data of patients undergoing EVAR for wide-neck AAA at three European vascular surgery units. All patients had computed tomography angiography follow-up of ≥24 months. The early end points were technical success and proximal type I endoleak at 30 days. The midterm end points were type Ia endoleak, freedom from reintervention (FFR), survival, AAA-related mortality, and infrarenal and suprarenal aortic diameter progression. The aortic diameters were measured on three-dimensional workstation center lumen line reconstructions, 1 cm below the lowest renal artery, at the level of the renal arteries, at the superior mesenteric artery, and at the celiac trunk. Preoperative and 24-month aortic diameters were compared by paired t-test. Survival and FFR were evaluated by Kaplan-Meier analysis. Results During the study period, 118 patients (74 ± 8 years) were enrolled. The mean aneurysm diameter was 61 ± 10 mm. Suprarenal and infrarenal fixation endografts were implanted in 102 (86%) and 16 (14%) patients, respectively. The mean main body oversizing was 17% ± 9%. Technical success rate was 98% (three type Ia endoleaks at 30 days). The mean follow-up was 38 ± 12 months. Fourteen type Ia endoleaks (12%) were detected during follow-up. Survival at 3 years and 5 years was 89% and 70%, respectively. Four deaths (3.4%) were type Ia endoleak related. FFR at 1 year, 3 years, and 5 years was 96%, 83%, and 82%, respectively. Eight reinterventions (7%) were proximal neck related. All infrarenal and suprarenal aortic diameters increased at 24 months. The mean increase was 11% for the lowest renal artery (29.1 ± 1.1 mm preoperatively vs 32.3 ± 4.5 mm at 24 months; P <.001), 3% to 5% at the level of the renal arteries, and <3% for the superior mesenteric artery and the celiac trunk. Neck length <15 mm (P =.032), stainless steel endograft (P =.003), and type Ia endoleak at 24 months (P =.001) were associated with infrarenal neck enlargement on multivariate logistic regression. Conclusions EVAR performed in AAAs with large necks is associated with a significant infrarenal aortic neck enlargement at 24 months as well as with a high risk of proximal type I endoleak and proximal neck-related reinterventions. In this subgroup of patients, main body oversizing >15% and suprarenal sealing should be considered.