Effect of the Alto Endovascular Aneurysm Repair Device on Postoperative Large Artery Stiffness

Large artery stiffness (LAS) adversely affects multiple organs. Endovascular aneurysm repair (EVAR) is associated with a postoperative increase in LAS; however, LAS responses may differ according to stent graft design. Ovation Alto is a novel abdominal EVAR device characterized by a nonscaffolded main body without a continuous metallic framework. We evaluated the impact of the Alto device on postoperative LAS compared with that of representative exoskeleton EVAR devices.

In this retrospective observational study, consecutive patients who underwent EVAR for abdominal or iliac artery aneurysms between January 2017 and October 2025 were screened. We included patients treated with a single-device platform using the Alto, ENDURANT II, or EXCLUDER. Pulse wave velocity (PWV) was measured noninvasively before and after EVAR, and the postoperative change in PWV (ΔPWV) was the primary end point.

In total, 116 patients were included (Alto, n = 28; ENDURANT, n = 53; and EXCLUDER, n = 35). PWV increased significantly after EVAR in patients treated with ENDURANT and EXCLUDER, whereas no significant postoperative changes in PWV were observed in the Alto group. In the multivariable analysis, change in mean blood pressure (ΔmBP), a history of ischemic heart disease, and exoskeleton design were independently associated with ΔPWV. In addition, a significant interaction between device type and ΔmBP was observed, indicating differential PWV responses to blood pressure changes according to device design.

The Alto device was not significantly associated with an increase in LAS. In addition, the relationship between blood pressure changes and PWV differed by device design, suggesting a device-specific hemodynamic response after EVAR.