Adjunctive E-XL stent reinforcement during EVAR and TEVAR in patients with hostile proximal neck anatomy: Early term outcomes

Aim: Hostile proximal neck anatomy may compromise endograft fixation and sealing during endovascular aortic repair. This study evaluated the early outcomes of adjunctive E-XL stent reinforcement during standard endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR) in selected patients with hostile proximal neck anatomy.

Material and Methods: Consecutive patients undergoing EVAR or TEVAR with adjunctive E-XL stent placement were retrospectively reviewed. Baseline characteristics, anatomical features, procedural variables, and early outcomes were obtained from medical records and imaging. Clinical follow-up was performed during the first postoperative week and at one month, with contrast-enhanced computed tomography at one month. 

Results: Twenty-one patients were included: 12 underwent TEVAR and nine EVAR. All TEVAR patients had proximal neck angulation > 60° (mean 75.4 ± 6.6°). In the EVAR group, hostile neck features included severe angulation, neck length < 15 mm, combined short and angulated neck, or circumferential thrombus > 2 mm. Technical success was achieved in all patients. No perioperative cerebrovascular or cardiovascular events, end-organ ischaemia, graft migration, type Ia endoleak, stent collapse, kinking, or limb stenosis occurred. Mild post-implantation syndrome occurred in three patients (14.3%). One patient died within one month from COVID-19, unrelated to the procedure. One distal type Ib endoleak after TEVAR was successfully treated with extension. Mean aneurysm diameter decreased by 1.1 mm after TEVAR and 0.6 mm after EVAR at one month; the clinical relevance of these small changes is uncertain.

Conclusion: Adjunctive E-XL reinforcement was technically feasible and may provide additional proximal fixation support in carefully selected high-risk patients when standard endograft fixation is considered potentially insufficient. These early findings do not establish long-term durability or comparative efficacy. Larger prospective comparative studies with extended imaging follow-up are required before routine use can be recommended.