Surgical Infrarenal “Neo-neck” Technique During Elective Conversion after EVAR with Suprarenal Fixation

Abstract

Preservation of the proximal covered stent of an endograft with suprarenal fixation used as an infrarenal "neo-neck" with incorporation of the aorta to the suture line during elective surgical explantation simplifies the procedure, and can be achieved with very low early morbidity and mortality; furthermore, it seems to be durable over mid-term follow up.

Open Conversion After Endovascular Abdominal Aneurysm Repair: An 8 year Single Centre Experience

“…After opening the aneurysmal sac, the stent graft was cut transversely using robust scissors at the level of the fabric whenever possible, and ideally between the two first covered stents. Thus, the proximal end to end anastomosis involved the proximal remaining stent graft component, aortic wall, and surgical graft to create a "neo-neck" as described by Bonvini et al 7 Prosthetic aortic reconstruction, using standard Dacron graft, was aorto-aortic tube in 12 cases, aorto-bi-iliac bypass in 14 cases, of which two had an additional unilateral aortofemoral bypass, and aorto-bi-femoral bypass in one case. Among three cases of stent graft infections, two Dacron Silver graft (1 tube, 1 bi-iliac bypass) and one cryopreserved arterial allograft (aorto-bi-iliac) were used.…”

“…However, attempts were made to partially remove the stent graft whenever possible, and to perform a proximal suture as described by Bonvini et al as the "neo-neck" technique. 7 In their series of previous suprarenal fixed EVAR, proximal anastomosis was performed with preservation of the first covered stent, and no degeneration of the residual infrarenal aortic neck was observed after mid-term follow-up.…”

Unique Technique for Open Surgical Repair after Failed Endovascular Aneurysm Repair with Proximal Anastomoses

“…The "neoneck'' technique has been reported recently. 8) Our strategy is similar to that "neo-neck'' procedure, which makes a new proximal anastomosis site composed of the first covered stent and the infrarenal aortic wall. Since it was assumed that it would be better to anastomose a new graft to the residual aortic wall and just the fabric than to the fabric with stent, the first stent was removed, but the bared top stents were preserved to keep a functional part of the endograft.…”

Open Surgical Conversion After Endovascular Aortic Aneurysm Repair

“…6,9 Clamping at a higher level increases the risk of visceral ischaemia, acute kidney injury, reperfusion injury, and cardiac complications. 10 Selective partial graft removal 2,5,6 has been used proximally, 3,4 but also distally in densely adherent iliac limbs. 3,8 The most used technique proximally is to cut the fabric of the endograft beyond the first covered stent together with its native aortic wall to create a "neo-neck" and to suture the surgical graft onto both aortic wall and the first covered stent.…”

“…3,8 The most used technique proximally is to cut the fabric of the endograft beyond the first covered stent together with its native aortic wall to create a "neo-neck" and to suture the surgical graft onto both aortic wall and the first covered stent. 10 For persistent type II endoleak with growth of the aneurysm sac, a so-called semi-conversion has been suggested and is often preferred. The semi-conversion consists of a laparotomy with opening of the aneurysm sac and ligation of lumbar arteries without clamping the aorta, to reduce mortality and morbidity.…”