This paper reviews the development of endovascular aneurysm repair (EVAR) of infra-renal aortic and iliac artery aneurysms and considers the current status and best treatment options. The vast majority of devices are bifurcated and exclude the aneurysm utilizing the same techniques for fixation and seal. The modern EVAR procedure is usually performed in a hybrid operating theatre, utilizing image fusion and other radiation-reducing techniques and using optimized procedural techniques, including percutaneous access. The best outcomes are achieved in patients whose anatomy is within device “instructions for use”, but these are most commonly breached due to “hostile” neck anatomy. Endovascular options for these cases include the use of fenestrated endografts, chimney grafts and endoanchors. Concomitant iliac artery aneurysms often occur with abdominal aortic aneurysms, and endovascular options include limb extensions with internal iliac embolization as well as iliac branch devices. The durability of EVAR has recently been called into question by long-term results from early EVAR randomized trial. Findings such as infra-renal neck dilatation and aneurysm sac expansion are relatively common and associated with adverse outcomes. This durability concern mandates regular and long-term imaging and clinical surveillance. It also indicates that EVAR technology is not fully evolved with a need for further development to improve patient applicability and long-term durability.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 1991;5:491–9.
Waasdorp EJ, de Vries JP, Hobo R, et al. Aneurysm diameter and proximal aortic neck diameter influence clinical outcome of endovascular abdominal aortic repair: a 4-year EUROSTAR experience. Ann Vasc Surg. 2005;19:755–61.
EVAR Trial Participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomized controlled trial. Lancet. 2004;264:843–8.
Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351:1607–18.
Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302:1535–42.
Greenhalgh RM, Brown LC, United Kingdom EVAR Trial Investigators, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1863–71.
De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881–9.
Patel R, Sweeting MJ, Powell JT, Greenhalgh RM, EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm in 15-years’ follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet. 2016;388:2366–74.
Van Schaik TG, Yeung KK, Verhagen HJ, et al. Long-term survival and secondary procedures after open or endovascular repair of abdominal aortic aneurysms. J Vasc Surg. 2017;66:1379–89.
Teijink JAW, Power AH, Böckler D, Peeters P, van Sterkenburg S, Bouwman LH, Verhagen HJ, Bosiers M, Riambau V, Becquemin JP, Cuypers P, van Sambeek M. Five year outcomes of the endurant stent graft for endovascular abdominal aortic aneurysm repair in the ENGAGE registry. Eur J Vasc Endovasc Surg. 2019;58(2):175–81.
Verhoeven EL, Katsargyris A, Bachoo P, Larzon T, Fisher R, Ettles D, Boyle JR, Brunkwall J, Böckler D, Florek HJ, Stella A, Kasprzak P, Verhagen H, Riambau V, GREAT European C3 Module Investigators. Real-world performance of the new C3 Gore excluder stent-graft: 1-year results from the European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT). Eur J Vasc Endovasc Surg. 2014;48(2):131–7.
Verzini F, Romano L, Parlani G, Isernia G, Simonte G, Loschi D, Lenti M, Cao P. Fourteen-year outcomes of abdominal aortic endovascular repair with the Zenith stent graft. J Vasc Surg. 2017;65(2):318–29.
Wermelink B, Willigendael EM, Smit C, Beuk RJ, Brusse-Keizer M, Meerwaldt R, Geelkerken RH. Radiation exposure in an endovascular aortic aneurysm repair program after introduction of a hybrid operating theater. J Vasc Surg. 2019;70(6):1927–34.
Ahmad W, Obeidi Y, Majd P, Brunkwall JS. The 2D-3D registration method in image fusion is accurate and helps to reduce the used contrast medium, radiation, and procedural time in standard EVAR procedures. Ann Vasc Surg. 2018;51:177–86.
Takeuchi Y, Morikage N, Matsuno Y, Nakamura T, Samura M, Ueda K, Harada T, Ikeda Y, Suehiro K, Ito H, Sakata K, Hamano K. Midterm outcomes of endovascular aortic aneurysm repair with carbon dioxide-guided angiography. Ann Vasc Surg. 2018;51:170–6.
Vierhout BP, Pol RA, El Moumni M, Zeebregts CJ. Arteriotomy closure devices in EVAR, TEVAR, and TAVR: a systematic review and meta-analysis of randomised clinical trials and cohort studies. Eur J Vasc Endovasc Surg. 2017;54(1):104–15.
Lata K, Kaki A, Grines C, Blank N, Elder M, Schreiber T. Pre-close technique of percutaneous closure for delayed hemostasis of large-bore femoral sheaths. J Interv Cardiol. 2018;31(4):504–10.
Ulug P, Sweeting MJ, von Allmen RS, Thompson SG, Powell JT, On behalf of the SWAN Collaborators. Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis. Lancet. 2017;389(10088):2482–91.
Antoniou G, Georgiadis G, Antoniou S, Kuhan G, Murray D. A meta-analysis of outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile and friendly neck anatomy. J Vasc Surg. 2013;57(2):527–38.
Howard DPJ, Marron CD, Sideso E, Puckridge PJ, Verhoeven ELG, Spark JI, Global Registry for Endovascular Aortic Treatment (GREAT) Investigators. Influence of proximal aortic neck diameter on durability of aneurysm sealing and overall survival in patients undergoing endovascular aneurysm repair. Real world data from the Gore Global Registry for Endovascular Aortic Treatment (GREAT). Eur J Vasc Endovasc Surg. 2018;56(2):189–99.
Ullery B, Tran K, Itoga N, Dalman R, Lee J. Natural history of gutter-related type 1A endoleaks after snorkel/chimney EVAR. J Vasc Surg. 2017;65(4):981–90.
Donas K, Lee J, Lachat M, Torsello G, Veith F. Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment in the treatment of complex aortic pathologies: the PERICLES registry. Ann Surg. 2015;262(3):546–53.
Linbald B, Bin Jabr A, Holst J, Malina M. Chimney grafts in aortic stent grafting: hazardous or useful technique? Systematic review of current data. EJVES. 2015;5096:722–31.
Jordan WD Jr, Mehta M, Varnagy D, Moore WM Jr, Arko FR, Joye J, Ouriel K, de Vries JP, Aneurysm Treatment using the Heli-FX Aortic Securement System Global Registry (ANCHOR) Workgroup Members. Results of the ANCHOR prospective, multicenter registry of EndoAnchors for type Ia endoleaks and endograft migration in patients with challenging anatomy. J Vasc Surg. 2014;60(4):885–92.
Muhs BE, Jordan W, Ouriel K, Rajaee S, de Vries J-P. Matched cohort comparison of endovascular abdominal aortic aneurysm repair with and without EndoAnchors. J Vasc Surg. 2018;67:1699–707.
Malas MB, Hicks CW, Jordan WD Jr, Hodgson KJ, Mills JL Sr, Makaroun MS, Belkin M, Fillinger MF, PYTHAGORAS Investigators. Five-year outcomes of the PYTHAGORAS U.S. clinical trial of the Aorfix endograft for endovascular aneurysm repair in patients with highly angulated aortic necks. J Vasc Surg. 2017;65(6):1598–607.
Rhee R, Peterson B, Moore E, Lepore M, Oderich G. Initial human experience with the GORE EXCLUDER conformable AAA endoprosthesis. J Vasc Surg Cases Innov Tech. 2019;5(3):319–22.
Krupski W, Selzman C, Floridia R, Strecker R, Nehler M, Whitehall T. Contemporary management of isolated iliac aneurysms. J Vasc Surg. 1998;28(1):1–13.
McCready R, Pairolero P, Gilmore J, Kazmier F, Cherry K, Hollier L. Isolated iliac artery aneurysms. Surgery. 1983;93(5):688–93.
Verzini F, Parlani G, Romano L, De Rnago P, Panuccioo G, Cao P. Endovascular treatment of iliac aneurysm: concurrent comparison of side branch endograft versus hypogastric exclusion. J Vasc Surg. 2009;49(5):1154–61.
Rayt HS, Brown MJ, Lambert KV, Fishwick NG, McCarthy MJ, London NJ, et al. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Interv Radiol. 2008;31:728–34.
Farahmand P, Becquemin J, Desgranges P, Allaire E, Marzelle J, Roudot-Thoraval F. Is hypogastric artery embolisation during endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg. 2008;35(4):429–35.
Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, European Society for Vascular Surgery (ESVS). Clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2019;57(1):8–93.
Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2–77.e2.
D’Oria M, Mastrorilli D, DeMartino R, Lepidi S. Current status of endovascular preservation of the internal iliac artery with iliac branch devices (IBD). Cardiovasc Interv Radiol. 2019;42:935–48.
Masciello F, Fargion AT, Pratesi G, Dorigo W, Pratesi C. A propensity score-matched comparison of two commercially available iliac branch devices in patients with similar clinical and anatomic preoperative features. J Vasc Surg. 2019. https://doi.org/10.1016/j.jvs.2019.07.058(Epub ahead of print).
Pearce B, Varu V, Glocker R, Novak Z, Jordan W, Lee J. Anatomic suitability of aortoiliac aneurysms for next generation branched systems. Ann Vasc Surg. 2015;29(1):69–75.
Lim C, Hussain S, Wiszniewski SP, Mosquera Arochena N, Szopinski P. Modified sandwich-graft technique employing aorfix and viabahn stent-grafts to preserve hypogastric flow in cases of complex aortoiliac and isolated common iliac artery aneurysms including the internal iliac artery ostium. Eur J Vasc Endovasc Surg. 2016;51:364–70.
Reimerink JJ, Hoornweg LL, Vahl AC, et al. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg. 2013;258:248–56.
Desgranges P, Kobeiter H, Katsahian S, et al. ECAR (Endovasculaire vs. Chirurgie dans les Anevrysmes Rompus): a French randomized controlled trial of endovascular vs. open surgical repair of ruptured aorto-illiac aneurysms. Presented at European Society for Vascular Surgery; Stockholm, Sweden; 2014.
Powell JT, Sweeting MJ, Thompson MM, Ashleigh R, Bell R, Gomes M, Greenhalgh RM, Grieve R, Heatley F, Hinchliffe RJ, Thompson SG, Ulug P, IMPROVE Trial Investigators. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ. 2014;348:f7661.
IMPROVE Trial Investigators. Endovascular strategy or open repair for ruptured abdominal aortic aneurysm: one-year outcomes from the IMPROVE randomized trial. Eur Heart J. 2015;36(31):2061–9.
Powell JT, Sweeting MJ, Ulug P, Thompson MM, Hinchliffe RJ, IMPROVE Trial Investigators. Comparative clinical effectiveness and cost effectiveness of endovascular strategy vs open repair for ruptured abdominal aortic aneurysm: three year results of the IMPROVE randomised trial. BMJ. 2017;359:4859.
Tassiopoulos AK, Monastiriotis S, Jordan WD, Muhs BE, Ouriel K, De Vries JP. Predictors of early aortic neck dilatation after endovascular aneurysm repair with EndoAnchors. J Vasc Surg. 2017;66(1):45–52.
Kouvelos G, Oikonomou K, Antoniou G, Verhoeven E, Katsargyris A. A systematic review of proximal neck dilatation after endovascular repair for abdominal aortic aneurysm. J Endovasc Ther. 2017;24(1):59–67.
Monahan T, Chuter T, Reilly L, Rapp J, Hiramoto J. Long-term follow-up of neck expansion, after endovascular aortic aneurysm repair. JVS. 2010;52(2):303–7.
Schanzer A, Greenberg RK, Hevelone N, Robinson WP, Eslami MH, Goldberg RJ, Messina L. Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair. Circulation. 2011;123(24):2848–55.
Fujimura N, Ichihashi S, Matsubara K, Shibutani S, Harada H, Obara H, Kichikawa K, Kitagawa Y. Type IIIb endoleak is not extremely rare and may be underdiagnosed after endovascular aneurysm repair. J Vasc Interv Radiol. 2019;30(9):1393–9.
Batti S, Cochennec F, Roudot-Thoraval F, Becquemin J. Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition. J Vasc Surg. 2013;57(5):1291–7.
Tadros R, Faries P, Ellozy S, Lookstein R, Vouyouka A, Schrier R, Kim J, Marin M. The impact of stent graft evolution on the results of endovascular aortic aneurysm repair. J Vasc Surg. 2014;59(6):1518–27.
Aziz A, Menias C, Sanchez L, Picus D, Saad N, Rubin B, Curci J, Geraghty P. Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion. J Vasc Surg. 2012;55(5):1263–7.
Li Q, Hou P. Sac embolization and side branch embolization for preventing type II endoleaks after endovascular aneurysm repair: a meta-analysis. J Endovasc Ther. 2020;27(1):109–16.
Carpenter JP, Cuff R, Buckley C, Healey C, Hussain S, Reijnen MM, Trani J, Böckler D, Investigators Nellix. One-year pivotal trial outcomes of the Nellix system for endovascular aneurysm sealing. J Vasc Surg. 2017;65(2):330–6.
Bastos Goncalves F, Luijtgaarden J, Hoeks S, Hendriks J, ten Raa S, Rouwet E, Stolker R, Verhagen H. Adequate seal and no endoleak on the first postoperative computed tomography angiography as criteria for no additional imaging up to 5 years after endovascular aneurysm repair. J Vasc Surg. 2013;57(6):1503–11.
The authors received no funding in the preparation of this paper.
Conflict of interest
The authors do not have any relevant conflicts of interest in the preparation of this paper.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Holden, A., Hill, A. Endoluminal Management of Infra-renal Aortic and Aorto-iliac Aneurysms. Cardiovasc Intervent Radiol 43, 1788–1797 (2020). https://doi.org/10.1007/s00270-020-02563-w
- Hostile neck