Technical modifications for endovascular infrarenal AAA repair for the angulated and dumbbell-shaped neck: the precuff Kilt technique

High risk surgical patients with abdominal aortic aneurysms and difficult infrarenal necks continue to be challenged when performing endovascular repair. Although fenestrated and branched endografts may ultimately be the main method of repair for these patients, their current limited availability has prompted the use of alternative endovascular techniques to enhance success of endovascular aortic aneurysm repair in patients with "dumbbell" shaped and angulated necks.

A retrospective review of all patients who underwent endovascular abdominal aneurysm repair with a predeployed aortic cuff (Kilt) at University of California, Los Angeles between January 2009 and April 2010 was performed.

Four patients underwent initial Kilt placement before endovascular abdominal aortic aneurysm (AAA) repair. The mean age of these patients was 78.0 + 7.0 years. All were American Society of Anesthesiologists class 3 patients with multiple medical comorbidities. All of them had angulated and dumbbell-shaped necks. Median follow-up period was 11 months (8-18 months). All patients had postoperative computed tomography at 1 and 6 months because of their high-risk neck anatomy. One patient was found to have a large type I endoleak on computed tomography 1 month postoperatively. He required placement of an additional aortic cuff and Palmaz stent, after which the endoleak was found to have resolved. There were no open conversions, aneurysm sac enlargement, or perioperative deaths.

Short-term follow-up suggests that the Kilt technique may be useful in certain high-risk patients with traditionally unfavorable anatomy for endovascular abdominal aortic aneurysm repair. It can be performed with minimal patient morbidity, even in high-risk patients. Anatomic features most amenable to this technique include dumbbell-shaped and angulated infrarenal necks.