Predictors of Abdominal Aortic Aneurysm Sac Enlargement After Endovascular Repair

OBJECTIVES: The majority of infrarenal abdominal aortic aneurysm (AAA) repairs in the United States are performed with endovascular methods. Baseline aortoiliac arterial anatomic characteristics are fundamental criteria for appropriate patient selection for endovascular aortic repair (EVAR) and key determinants of long-term success. We evaluated compliance with anatomic guidelines for EVAR and the relationship between baseline aortoiliac arterial anatomy and post-EVAR AAA sac enlargement.

METHODS: Patients with pre-EVAR and at least 1 post-EVAR computed tomography scan were identified from the M2S, Inc. imaging database (1999 to 2008). Preoperative baseline aortoiliac anatomic characteristics were reviewed for each patient. Data relating to the specific AAA endovascular device implanted were not available. Therefore, morphological measurements were compared with the most liberal and the most conservative published anatomic guidelines as stated in each manufacturer’s instructions for use.

RESULTS: The primary study outcome was post-EVAR AAA sac enlargement (>5-mm diameter increase). In 10 228 patients undergoing EVAR, 59% had a maximum AAA diameter below the 55-mm threshold at which intervention is recommended over surveillance. Only 42% of patients had anatomy that met the most conservative definition of device instructions for use; 69% met the most liberal definition of device instructions for use. The 5-year post-EVAR rate of AAA sac enlargement was 41%. Independent predictors of AAA sac enlargement included endoleak, age ≥80 years, aortic neck diameter ≥28 mm, aortic neck angle >60°, and common iliac artery diameter >20 mm.

CONCLUSIONS: In this multicenter observational study, compliance with EVAR device guidelines was low and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture. Neville Hewitt Authentic Jersey

PMID: 21478500

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  1. See associated editorial:

    Endovascular repair of abdominal aortic aneurysm: no cause for alarm.
    Cambria RP.
    Circulation. 2011 Jun 21;123(24):2782-3.

  2. We had a lively multidisciplinary review of the article involving cardiology, vascular surgery/medicine, RADS, and IR. While the conclusions seem to point strongly in the direction of EVAR implantations being performed outside of MFGS guidelines, the real issue was the structure of the study. Examples: why were clinicians implanting EVARs in pts that had < 5.5 cm AAAs? Where they at high risk of rupture, were they enlarging rapidly, $$$? What limitations were inherently put into the study by the availability of CT scans, their standardization, the time frames associated with them during f/u. What was the overall aim/purpose of the study? Look forward to future JCs at CCF!

  3. This is a remarkable study due to the number of patients that were included in the analysis and the incredible amount of work that the authors did.
    Unfortunately, that may be not only be its biggest strength but also its only one.
    There seems to be an important bias in patient inclusion based on where the patient images were acquired by that core lab, as such will not represent an actual clinical cohort for example.

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