Technical tips for endovascular treatment of abdominal aortic aneurysms with challenging infrarenal neck anatomy using the excluder endoprosthesis

Purpose: To report technical tips of endovascular aneurysm repair using Excluder endografts in patients with challenging infrarenal neck anatomy (short, angled, and/or tapered necks). Technique: Several tips are presented to achieve effective and durable fixation and sealing of Excluder stent-grafts in abdominal aortic aneurysms (AAA) with challenging necks. The primary approach to patients with short infrarenal necks is a slow and controlled deployment combined with the bending-the-wire technique to realign the axis of the aneurysm and the axis of the neck. Severe infrarenal neck angulation is dealt with by bending the guidewire, orienting the iliac limbs of the Excluder in the anteroposterior direction, and using the slow and controlled endograft deployment technique. Other key procedural factors, such as using the percutaneous approach and local anesthetic, reorienting the stent-graft, using Excluder aortic extensions, employing the endowedge and kilt techniques, and using the appropriate C-arm angulation to adequately visualize the target landing zone, are also useful. Conclusion: The techniques we describe have been valuable in achieving excellent outcomes with endovascular AAA treatment using the Excluder endoprosthesis in challenging infrarenal neck anatomy. Further improvements in device design and deployment mechanism will allow better device alignment in patients with complex infrarenal neck anatomy.