Objective: Endovascular aneurysm repair (EVAR) has become the first line treatment for
abdominal aortic aneurysms with lower perioperative mortality and morbidity compared with
open repair. However long-term durability is not sustained. Aortic neck morphology influence
stent graft durability, and baseline aorta anatomic characteristics are fundamental for selecting
patients who are suitable for EVAR. This study aimed to evaluate the association between
anatomical and proximal sealing zone characteristics on long-term stent graft complications in
the early era of EVAR.
Methods: In this large retrospective cohort study, we included all consecutive patients
(n=279) with an infra-renal AAA who underwent EVAR between July 2008 and December
2013. We measured the anatomic variables of preoperative and postoperative CT-scans, using
central luminal line reconstructions. Stent graft related reinterventions and complications
Results: A total of 230 patients were included, the mean age was 76 [IQR 71—82], and
12.6% were female. The median follow-up was 3.6 years, and overall mortality was 38.3%.
Twenty-six per cent of patients had first stent graft related complications and 22.6% required
reintervention. Hundred-sixty-five patients there pre- and postoperative scans were available
and evaluated. Among patients with stent graft related complications, the proximal seal length
was significant shorter compared with the group without complication (15 mm vs. 22 mm,
p=0.004). In patients with a shorter aortic neck length we achieve less sealing length then is
calculated (p=<0.001). Dilation of the initial neck diameter with more than 10% is associated
with more stent graft complications (OR 2.2, 95% CI 1.2—4.3). Seventeen patients (7.8%)
developed a type 1a endoleak during follow-up. Patients with a shorter aortic neck length (OR
1.0 per mm, 95% CI 0.9 – 1.0) and lesser seal length (OR 0.9 95% CI 0.8 – 0.9) developed
significant more type 1a endoleaks.
Conclusion: Our large retrospective study about the early experience with EVAR showed a
high rate of stent-related complications and reinterventions. The proximal seal length during
implantation is a protective factor for stent graft complication and type 1a endoleak. Also, we
achieve an even significantly less proximal seal than is pre-calculated in patients with a
shorter proximal neck and is consequently associated with more complications and type 1a
endoleak. This underlines the importance of sealing in a “healthy” and longer part of the aorta
and redefining the IFU is perhaps required. Better patient selection or creating a seal in a
more proximal part of the aorta is recommended. Further research is needed for durability
with a more recent cohort.
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