Morphology and outcomes of endovascular repair of ruptured abdominal aortic aneurysms with hostile neck anatomy.

Abstract

Ruptured abdominal aortic aneurysms (rAAAs) have a high rate of hostile neck anatomy (HNA). The objective of this study was to evaluate the risk factors associated with intraoperative type Ia endoleak (T1EL) in endovascular repair (EVAR) for rAAAs with HNA, and to determine the association of intra-operative T1EL with long-term survival. The second objective was to delineate the visceral anatomy of rAAAs with HNA to determine the anatomic feasibility of the Cook p-Branch device. A multi-center retrospective review was performed to identify patients with rAAAs and HNA between 2004 and 2021. HNA was defined as infrarenal aortic neck diameter >28 mm, infrarenal neck length <15 mm, or angulation >60 degrees. Clinical characteristics and morphology were reviewed for predictors of intraoperative T1EL. The Kaplan-Meier method was used to estimate survival. The anatomic feasibility of the Cook p-Branch was reviewed. Eighty-five patients underwent standard EVAR for rAAAs with HNA. Mean age was 75 ± 10 years, and 74% were male. Twenty-four patients (28%) required adjunctive procedures for an intraoperative T1EL. Large aneurysm size (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.05; P = .02), increased distance from the renal arteries to the aortic bifurcation (OR, 1.02; 95% CI, 1.00-1.04; P = .04) and lower thrombus burden (OR, 0.57; 95% CI, 0.34-0.96; P = .03) were associated with intraoperative T1EL and the need for adjunctive procedures on univariate analysis. Overall survival for patients who underwent standard EVAR at 30 days, 1 year, and 5 years was 84%, 74%, and 64%, respectively. There was no difference in 30-day (84% vs 83%; P = .99), 1-year (75% vs 71%; Log-rank P = .73), or 5-year survival (67% vs 54%; Log-rank P = .34) in patients without an intraoperative T1EL vs patients with a T1EL who required an adjunctive procedure. There was also no difference in 1-year (98% vs 96%; Log-rank P = .48) or 5-year (85% vs 92%; Log-rank P = .51) aortic-related reintervention. No specific morphologic features within this population were predictive of aortic-related reintervention at 5 years. The visceral vessel applicability of the Cook p-Branch was 65%, and the overall applicability was only 56%. Despite a high rate of adjunctive intra-operative procedures for T1EL in patients who underwent EVAR for rAAAs with HNA, this was not associated with a significant difference in survival or aortic-related reintervention. The overall applicability of the Cook p-Branch device in patients with rAAAs and HNA is low, and standard EVAR is effective.