Endoluminal Management of Infra-renal Aortic and Aorto-iliac Aneurysms
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REVIEW
Endoluminal Management of Infra-renal Aortic and Aorto-iliac Aneurysms Andrew Holden1
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Andrew Hill1
Received: 21 February 2020 / Accepted: 10 June 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
Abstract This paper reviews the development of endovascular aneurysm repair (EVAR) of infra-renal aortic and iliac artery aneurysms and considers the current status and best treatment options. The vast majority of devices are bifurcated and exclude the aneurysm utilizing the same techniques for fixation and seal. The modern EVAR procedure is usually performed in a hybrid operating theatre, utilizing image fusion and other radiation-reducing techniques and using optimized procedural techniques, including percutaneous access. The best outcomes are achieved in patients whose anatomy is within device ‘‘instructions for use’’, but these are most commonly breached due to ‘‘hostile’’ neck anatomy. Endovascular options for these cases include the use of fenestrated endografts, chimney grafts and endoanchors. Concomitant iliac artery aneurysms often occur with abdominal aortic aneurysms, and endovascular options include limb extensions with internal iliac embolization as well as iliac branch devices. The durability of EVAR has recently been called into question by long-term results from early EVAR randomized trial. Findings such as infra-renal neck dilatation and aneurysm sac expansion are relatively common and associated with adverse outcomes. This durability concern mandates regular and long-term imaging and clinical surveillance. It also indicates that EVAR technology is not fully evolved with a need for further development to improve patient applicability and long-term durability.
Fact Sheet Ten most important points regarding endoluminal management of infra-renal aortic and aorto-iliac aneurysm: •
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Keywords EVAR Durability Hostile neck IFU & Andrew Holden [email protected] 1
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EVAR for elective repair of infra-renal AAA is associated with reduced 30-day morbidity and mortality compared to open surgical repair. The mortality benefit for EVAR is lost by 2 years, and landmark randomized trials have suggested a late survival benefit for open repair. Industry-sponsored registries have shown modern EVAR devices perform extremely well acutely when used within company instructions for use in terms of freedom from type 1 and 3 endoleak, migration and aneurysm rupture. Internal iliac artery preservation is important when treating iliac artery aneurysms and is best achieved with iliac branched devices. The use of dedicated hybrid operating rooms with image fusion is now routine and potentially reduces procedure time as well as radiation and contrast dose. Percutaneous EVAR with closure devices is now feasible in most cases with technical success largely driven by the quality of the common femoral artery rather than access sheath size. Options for hostile infra-renal neck anatomy include fene
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