The combined use of thoracic and abdominal aortic stent grafts for endovascular repair of wide neck abdominal aortic aneurysms in high risk patients

Introduction: Treatment of abdominal aortic aneurysms (AAA) with large (28 mm to 34 mm) and wide diameter (> 35 mm) necks remains a challenge in patients who are high-risk candidates for open repair. While several case reports describe the use of a thoracic stent graft in conjunction with a traditional modular bifurcated stent graft, most patients do not have the aortic length to accommodate such a configuration. We present our experience utilizing a distal unibody bifurcated aortic stent graft (Endologix, Irvine, CA) in conjunction with a proximal thoracic aortic stent graft (Medtronic, Minneapolis, MN) to treat wide-necked non-ruptured AAAs in patients who were otherwise poor candidates for open or fenestrated repair. Methods: A single center retrospective review of patients treated with a combination of a distal unibody bifurcated aortic stent graft and a proximal thoracic aortic stent graft extension from 2013 to 2019 was performed. Demographics, perioperative details and long-term outcomes were collected and summarized. Standard statistical methods were utilized. Results: We identified 7 patients who underwent this procedure during the study interval. Of these, all 7 (100%) were male with an average age of 69.1 +/- 5.1 years. Average Charlson Comorbidity Index was 5.0. Average pre-operative maximum aortic and neck diameters were 57.9 mm (+/- 5.8) and 37.4 mm (+/- 4.5) respectively. All patients underwent repair with a distal 28 mm diameter unibody bifurcated aortic stent graft and proximal extension with a thoracic aortic stent graft that ranged from 40 to 46 mm in diameter. Technical success was achieved in all 7 patients. There were no perioperative mortalities or aorta-related deaths. Follow up was a mean of 1.98 years with a mean survival of 4.75 years (+/- 0.86). One patient required an aneurysm-related intervention for a late type III endoleak. Conclusion: The combined use of thoracic and abdominal aortic stent grafts is a safe and effective endovascular method to treat high-risk surgical candidates with wide-necked AAAs.