Endovascular repair of abdominal aortic aneurysm with severely angulated neck and tortuous artery access: case report and literature review

Abstract

BackgroundEndovascular aneurysm repair has revolutionized the therapeutic strategy for abdominal aortic aneurysm. However, hostile proximal aneurysmal neck and tortuosity of access vessels remain challenges in selecting optimal stent-grafts in abdominal aortic aneurysms with difficult anatomy.Case presentationA 65-year-old woman complained of intermittent abdominal pain for one week. Computed tomography angiogram demonstrated a tortuous infrarenal abdominal aortic aneurysm with a tapered neck and a 136° of infrarenal angulation. Aneurysmal dilatation and severe calcification of bilateral iliac arteries and tortuous aortoiliac access were also showed. Endovascular approach using Endurant stent-graft was attempted at an outside hospital, but failed because of the significant tortuosity of the abdominal aorta and iliac arteries. Since the patient refused to have open aneurysm repair, he was transferred to our hospital for further evaluation and possible EVAR with a different approach. EVAR was performed successfully using Gore Excluder stent-grafts (W.L. Gore & Associates, Flagstaff, AZ, USA). During the procedure, cannulation of the contralateral limb was unable to be achieved because of the tortuous aortoiliac course. Therefore, a snare was inserted from right radial artery, through the contralateral gate, to grasp the wire from left femoral artery. Two iliac stent-grafts were sequentially deployed with the lower end distal to the opening of the left internal iliac artery. Angiography confirmed complete sealing of the aneurysm with patency of bilateral renal arteries and external iliac arteries. The postoperative courses were uneventful and follow-up computed tomography angiogram at 6 months demonstrated patent bilateral femoral and renal arteries without endoleaks or stent migration.ConclusionAlthough endovascular repair of aortic aneurysm with hostile neck and tortuous access is rather challenging, choosing flexible stent-grafts and suitable techniques is able to achieve an encouraging outcome.

Endovascular aortic repair with the Gore Excluder Conformable endograft in severe neck angulation: Preliminary experience and technical aspects

“…14 Treatment of a highly angulated neck (136°) in a quite long proximal aortic neck (23 mm) with the standard Gore Excluder device outside IFU was previously reported in literature. 15 We believe that the association of high adaptability in tortuous anatomy of the standard graft, the conformable flexibility of the proximal end and the reposition system could be the ideal approach to SNA.…”

Preliminary Dual-Center Experience with the Bolton Treovance Endograft

“…12,13 These factors, in combination with patient comorbidities, may have played a role in the development of the early endoleaks. However, one cannot entirely rule out the possibility of operator error, such as incorrect graft sizing or positioning, Hostile anatomies pose a restriction to widespread application of EVAR 14 : a meta-analysis comparing outcomes of 5 devices (AneuRx, Talent, Endurant, Zenith, and Excluder) in hostile versus nonhostile anatomy demonstrated a 4-fold increased risk of type I endoleaks and a 9-fold increased risk of aneurysm-related mortality at 1 year. 15 In our experience, however, the performance of Treovance in patients with hostile neck anatomies was comparable to those with nonhostile anatomies, with no statistical difference in adjunctive procedure, reintervention, and complication occurrence ( Table 2).…”

Repair of abdominal aortic aneurysms: preoperative imaging and evaluation

“…Unfavorable neck angulation greater than 60 degrees has been considered to be a contraindication to EVAR, although recent studies using more modern, conformable endografts have demonstrated the efficacy of EVAR treatment in patients with unfavorable neck angulation without significant differences in primary or secondary outcomes of EVAR 4 years out (21,(45)(46)(47). Further long-term results with these modern endograft devices are still ongoing (47).…”