Use of combined thoracic and abdominal endografts for proximal severe neck angulation in abdominal aortic aneurysms.

Purpose: To evaluate endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) with severe neck angulation (SNA) utilizing a thoracic endograft placed proximal to a bifurcated endograft.

Methods: A retrospective review was conducted of 28 consecutive EVAR patients (25 men; mean age 71 years, range 62-86) with proximal SNA ≥60° treated electively between December 2006 and May 2011. The average AAA neck diameter was 23 mm (range 22-28), with a mean length of 25 mm (range 10-51) and a mean maximum sac diameter of 63 mm (range 55-98). The mean neck angulation was 73° (range 60-92). All patients received an endograft designed for the thoracic aorta (Relay) placed as a proximal extension above a bifurcated abdominal aortic endograft (IntuiTrak Powerlink).

Results: Technical success was achieved in 100% of cases. An intraoperative type I proximal endoleak was successfully treated with stent deployment, and 2 type II endoleaks spontaneously resolved within 30 days. In all 28 patients, endograft integrity and correct positioning were confirmed at the latest imaging follow-up (mean 23.7 months, range 6-43). Fifteen (56%) aneurysm sacs were stable and 13 (46%) were reduced in size. Two patients died of unrelated causes during follow-up.

Conclusion: The unique morphology of SNA requires the development of a precise proximal fixation technology for successful endovascular repair. This hybrid solution exploits the technological advances of the thoracic aortic endograft and the stability of an anatomically fixed bifurcated endograft. This device combination may be an alternative solution for patients with SNA who are unsuitable for traditional surgery.