Distal Landing Zone-Related Complications of Conventional Endovascular Aneurysm Repair (EVAR) in the Long Term: A Comprehensive Systematic Review.

The aim of this systematic review is to evaluate the late-onset complications considering the distal landing zones (DLZ) in patients with abdominal aortic aneurysm (AAA) treated by conventional endovascular aneurysm repair (EVAR). We conducted a systematic review of electronic databases, clinical trial registries, and grey literature to retrieve studies on this issue. The inclusion criteria could be summarized as follows: (1) observational studies or case series with more than 30 patients included, (2) at least three-year follow-up, and (3) endpoints including endoleak type Ib (ELIB) or cranial iliac limb migration/retraction (CLR) or DLZ failure-related reinterventions or other complications. Of the 517 potentially eligible studies, the detailed search revealed eight articles with a total of 2569 patients for further investigation. Due to the extreme heterogeneity in definitions and reporting outcomes among the included studies, the synthesis and meta-analysis of data were not plausible. A quantitative assessment of reported outcomes revealed a pooled incidence of 2.1% for ELIB, 1.7% for CLR, and 5.7% for DLZ failure-related reinterventions. Data were considered controversial to extract a consensus for the dilatation of the DLZ. This systematic review delineates the importance of late-onset complications originating from DLZ failures for the longevity of an EVAR procedure and gathers the current knowledge regarding the magnitude and clinical implications of DLZ failure from the existing literature and in the best available quality. Current literature data show a blurred image regarding the long-term morphological alterations of iliac arteries and especially in the impact of DLZ dilatation and emphasize the necessity of prolonged follow-up for at least five years.