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

Objective: 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 intra-operative 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.

Methods: 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 intra-operative T1EL. The Kaplan-Meier method was used to estimate survival. The anatomic feasibility of the Cook p-Branch was reviewed.

Results: Eighty-five patients underwent standard EVAR for rAAAs with HNA. Mean age was 75 ± 10 years and 74% were male. Twenty-four (28%) patients required adjunctive procedures for an intra-operative T1EL. Large aneurysm size (OR 1.03, CI 1.00-1.05, P = .02), increased distance from the renal arteries to the aortic bifurcation (OR 1.02, CI 1.00-1.04, P = .04) and lower thrombus burden (OR 0.57, CI 0.34-0.96, P = .03) were associated with intra-operative 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 intra-operative T1EL versus 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 re-intervention at 5 years. The visceral vessel applicability of the Cook p-Branch was 65% and the overall applicability was only 56%.

Conclusion: 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.