Failure of endovascular aortoaortic tube grafts: a plea for preferential use of bifurcated grafts.

OBJECTIVE: Aortoaortic tube graft repair was the first technique used for the endovascular treatment of abdominal aortic aneurysms (AAAs). However, progressive changes in the morphology of the distal aortic neck may be responsible for procedural failure. This study examines the use of aortoaortic tube prostheses and analyzes the factors that contributed to their failure and the methods used for their subsequent repair. METHODS: During a 7-year period, 462 patients with abdominal aortic aneurysms underwent endovascular aortic aneurysm repair. Of these, 65 patients (14%) underwent treatment with aortoaortic tube endoprostheses. Aortoaortic tube prostheses used included Talent (n = 44) (Medtronic-Worldmedical, Sunrise, Fla), Vanguard (n = 8) (Boston Scientific, Natick, Mass), EVT/Ancure (n = 4) (Guidant, Menlo Park, Calif), and physician-fabricated (n = 9). All the tube graft procedures were performed in the operating room with fluoroscopic guidance. The average age of patients for aortoaortic tube grafts was 74.5 years, and 48 of the patients were men. Failure was defined as aneurysm expansion, any type I endoleak, or type II endoleak persistent after 6 months. RESULTS: No aneurysm ruptures or perioperative deaths were seen. Retrograde aneurysm perfusion from lumbar or inferior mesenteric arteries (type II endoleak) that persisted beyond 6 months was present in three patients. Proximal attachment site endoleaks were present in two patients. No distal implantation site endoleaks were present within 1 month of the initial endovascular repair; however, endoleaks at the distal attachment site developed in 12 patients subsequently and included all graft types (Talent, n = 6; Vanguard, n = 2; Ancure/EVT, n = 1; physician-fabricated, n = 3). The average time interval to failure was 12.9 months. Preoperative distal aortic neck length showed a significant correlation with the subsequent development of distal endoleak (endoleak, 16.6 +/- 6.8 versus no endoleak, 23.3 +/- 9.6; P =.03). Preoperative distal aortic neck diameter, however, did not show significance (23.8 +/- 5.2 versus 22.6 +/- 4.7; P = not significant). CONCLUSION: Endovascular aortoaortic tube grafts are vulnerable to failure even when initial exclusion of the aneurysm is successful. A significant association is seen between distal neck length and eventual failure. Because of the propensity toward eventual failure, the use of aortoaortic tube grafts in the infrarenal aorta cannot be recommended for typical fusiform aneurysms, even when an adequate distal neck appears to be present.