Cardiovasc Intervent Radiol (2012) 35:1009–1015
DOI 10.1007/s00270-011-0229-4
CLINICAL INVESTIGATION
Morphological State as a Predictor for Reintervention
and Mortality After EVAR for AAA
Tomas Ohrlander • Magnus Dencker •
Stefan Acosta
Received: 25 May 2011 / Accepted: 23 June 2011 / Published online: 20 July 2011
Ó Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2011
Abstract
Purpose This study was designed to assess aorto-iliac
morphological characteristics in relation to reintervention
and all-cause long-term mortality in patients undergoing
standard EVAR for infrarenal AAA.
Methods Patients treated with EVAR (ZenithÒ Stent-
grafts, Cook) between May 1998 and February 2006 were
prospectively enrolled in a computerized database where
comorbidities and preoperative aneurysm morphology
were entered. Reinterventions and mortality were checked
until December 1, 2010. Median follow-up time was
68 months.
Results A total of 304 patients were included, of which
86% were men. Median age was 74 years. The reinter-
vention rate was 23.4% (71/304). A greater diameter of the
common iliac artery (p = 0.037; hazard ratio (HR) 1.037
[1.002–1.073]) was an independent factor for an increased
number of reinterventions. The 30-day mortality rate was
3.0% (9/304). Aneurysm-related deaths due to AAA
occurred in 4.9% (15/304). Five patients died due to a
concomitant ruptured thoracic aortic aneurysm. The mor-
tality until end of follow-up was 54.3% (165/304). The
proportion of deaths caused by vascular diseases was
61.6%. The severity of angulation of the iliac arteries
T. Ohrlander
Eksjö County Hospital, Malmö, Sweden
M. Dencker
Department of Clinical Physiology and Nuclear Medicine,
Malmö University Hospital, Malmö, Sweden
S. Acosta (&)
Vascular Center Malmö-Lund, Malmö University Hospital,
205 02 Malmö, Sweden
e-mail: stefan.acosta@telia.com
ARTERIAL INTERVENTIONS
(p = 0.014; HR 1.018 [95% confidence interval (CI)
1.004–1.033]) and anemia (p = 0.044; HR 2.79 [95% CI
1.029–7.556]) remained as independent factors associated
with all-cause long-term mortality. The crude reinterven-
tion-free survival rate at 1, 3, and 5 years was 84.5%,
64.8%, and 51.6%, respectively.
Conclusions The initial aorto-iliac morphological state in
patients scheduled for standard EVAR for AAA seems to
be strongly related to the need for reinterventions and
long-term mortality.
Keywords Endovascular Aneurysm Repair
Abdominal
Aortic Aneurysms Morphology
Reintervention
Mortality
Introduction
Technologies in endovascular aneurysm repair (EVAR) for
abdominal aortic aneurysms (AAA) have evolved rapidly
in recent years. In highly specialized centers, there are now
few situations where an endovascular option does not exist
[1]. The majority of AAAs, however, can be treated
straight-forward by implantation of an infrarenal bifurcated
stentgraft in most vascular centers. The Vascular Center,
Malmö University Hospital, has a long experience in per-
forming EVAR procedures [2] and has since 1998 been
using the ZenithÒ bifurcated stentgraft. It is important to
report on factors associated with long-term outcome in
term of reinterventions and mortality in these more easily
treated patients, because more centers are starting to offer
their AAA patients this less-invasive technique. This study
was designed to analyze baseline factors and, in particular,
the influence of the initial aorto-iliac morphological state in
relation to reintervention and long-term mortality after
standard EVAR for infrarenal AAA.
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1010 T. Ohrlander et al.: Morphological State as a Predictor

Methods

Patients

The Vascular Center, Malmö-Lund is a tertiary referral

center for patients with vascular disease. This study
comprised consecutive patients who underwent elective,
nonfenestrated EVAR for infrarenal nonruptured AAA
between May 1998 and February 2006. The patients were
identified in the prospective database for endovascular
interventions where comorbidities, pre-, per-, and postop-
erative data were registered. Complementary clinical data
were retrieved from patient records. The data were retro-
spectively analyzed.

Aorto-Iliac Morphology Measurements

Preoperative evaluation included contrast-enhanced spiral

computed tomography (CT) in all patients. In addition,
digital subtraction angiography was performed in all
EVAR patients during the first half of the study period. The
shortest transverse diameter of the arteries was measured
using callipers against a centimeter scale on hard-copy
films by the same observer (physician). AAA and common
iliac artery maximal diameter was measured transversally
at its widest portion. The aorta between the lowest renal
artery and the beginning of the aneurysm is referred to as
the proximal neck. Neck diameter was measured at the
level of the lowest renal artery. The proximal neck angu-
lation and maximal angulation of the iliac arteries were
measured as illustrated in Fig. 1.
EVAR
EVAR was performed with ZenithÒ stentgrafts (Cook
Europe A/S, Bjaeverskov, Denmark). In general, anatom-
ical suitability for EVAR included proximal neck diame-
ter B 30 mm, angulation B 90°, and length C 12 mm. For
distal implantation, at least one common iliac artery with a
distal diameter B 20 mm was required. All cases were
performed within instructions for use. A total of 278
bifurcated, 23 aorto-uniiliac and femoral-femoral crossover
bypasses, and 2 aorto-aortic stentgrafts were inserted. In
general, all patients with type I or III endoleaks were
considered for revision during intervention or in the same
admission. The procedures were performed exclusively
with endovascular technique by using percutaneous closure
devices at the femoral access sites in 47% of the cases. One
peroperative conversion to open surgery was performed.
EVAR procedures were performed in the operation room.
A portable C-arm (Siremobil 2000, Siemens, Erlangen,
Germany) was used until October 2000. Since then, an
Fig. 1 Aorto-iliac morphology measurements. L proximal neck
length, D maximal AAA diameter measured transversally at its
widest portion, a proximal neck angulation, b maximal angulation of
the iliac arteries. Schematic drawing was kindly provided by Anders
Wanhainen
operation room fully equipped as an angio suite (Angiostar
Plus OR, Siemens, Erlangen, Germany) has been used.
Follow-up
All patients were monitored from the day of EVAR until
death or December 1, 2010. Median follow-up time was
68 months. All patients were seen at the outpatient clinic at
1 month and 1 year postoperatively. The patients underwent
a contrast-enhanced CT and a plain abdominal film regularly
every year. Follow-up mortality data were retrieved from the
Swedish Population Registry. The causes of deaths (death
certificates) were obtained from the National Board of
Health and Welfare. This study was approved by the
Research Ethics Committee at the University of Lund.
Definitions
Hypertension was defined as systolic blood pressure [
140 mmHg or diastolic blood pressure [ 90 mmHg, or
both, on at least two different occasions. Hypertension was
considered if the patient had been diagnosed previously
with hypertension or was taking antihypertensive medica-
tion. Cerebrovascular disease was considered if there was a
history of stroke (cerebral bleeding or infarction) or tran-
sient ischemic attack (TIA). Ischemic heart disease was
considered if there was a history of myocardial infarction,
angina pectoris, coronary artery bypass graft, or

123
T. Ohrlander et al.: Morphological State as a Predictor
percutaneous coronary angioplasty. Diabetes mellitus was
noted if the patient had antidiabetic treatment with diet,
oral hypoglycemic agents, or insulin.
Smoking included both current and former tobacco
smokers. Renal insufficiency was present if glomerular
filtration rate (GFR) was \60 ml/min in patients aged
50–65 years and \50 ml/min in patients aged [65 years.
The Cockroft-Gault formula includes serum creatinine,
age, weight, and gender to calculate GFR [3]. Anemia was
defined as hemoglobin \134 g/L in men and \117 g/L in
women.
Statistical Methods
Data management and statistical analysis were performed
using SPSS 17.0 software (SPSS, Inc., Chicago, IL).
Analysis was performed on an intention-to-treat basis.
Differences in proportions were evaluated using the
chi-square test or Kendall tau-b test. Correlations were
evaluated with the Pearson’s correlation coefficient.
Comparisons between groups by using continuous vari-
ables were made with the Mann–Whitney U test. Patient
survival was analysed according to the Kaplan–Meier
method. Variables associated with reintervention or death
during follow-up were further tested in a multivariate Cox
regression model, with all variables (p \ 0.1) entered into
the model. Significant associations were expressed in terms
of hazard ratios (HR) with 95% confidence intervals (CI);
and p \ 0.05 was considered significant.
Results
Patient Characteristics
A total of 304 patients were included. Median age was
74 years, and 261 (86%) patients were men. Both hyper-
tension and smoking were found in 85% of the patients,
and renal insufficiency and anemia were prevalent in 30%
and 35%, respectively (Table 1).
Aorto-Iliac Initial Morphological State
The distribution of the anatomical properties of the aorto-
iliac segments and of the aortic aneurysms in the study
patients are shown in Table 2. The median (IQR) length
and diameter of the proximal neck was measured to 27
(20–36) mm and 23 (22–26) mm, respectively. The median
proximal neck angulation was 45 (30–60) degrees. The
median maximal transverse aneurysm diameter was 59
(53–67) mm. The median maximal angulation of the iliac
arteries was 90 (70–90) degrees. The median maximal
1011
Table 1 Patient characteristics in 304 patients who underwent
EVAR
Variable
Age (year) 74 (IQR 70–79)
Sex (M/F) 261 (86)/43 (14)
History of Percentage
of patients
Hypertension 85.2
Smoking 85.4
Diabetes mellitus 10.9
Ischemic heart disease 42.1
Cerebrovascular disease 15.1
Peripheral arterial occlusive disease 11.5
Renal insufficiency 29.8
Anemia 34.8
transverse diameter of the common iliac arteries was 19
(16–23) mm. The median length of the right and left
common iliac arteries was 55 (50–60) mm and 55 (50–60)
mm, respectively. The median smallest diameter of the
external iliac arteries was 8 (7–9) mm. There was a sig-
nificant correlation between lower haemoglobin levels and
larger aneurysm diameters (p = 0.008; r = -0.157).
Reinterventions
Endoleaks were seen in 19.9% and 7.8% of the patients at
anytime and at the final CT examination, respectively,
during follow-up. The reintervention rate among the study
patients during follow-up was 23.4% (71/304). Forty-one
patients underwent one reintervention. Eighteen, seven,
three, and two patients underwent two, three, four, and
seven reinterventions, respectively. The median time to the
first reintervention was 15 (range, 0–100) months. The
most common reintervention procedure was stenting of the
stentgraft limbs in the iliac arteries. Both endovascular and
open surgical reinterventions were counted as reinterven-
tions (Table 3). There were four conversions to open AAA
repair: one due to stentgraft infection, and three late rup-
tures of AAA, of whom two were treated endovascularly.
Patient and Aorto-Iliac Characteristics in Relation
to Reinterventions
Among the variables tested in Table 1, only younger age
(p = 0.026) was found to be associated with an increased
number of reinterventions. Among the seven aorto-iliac
attributes described in Table 2, a greater diameter of the
common iliac artery (p \ 0.001), severity of angulation of
the proximal neck (p = 0.044), and a lesser diameter of the
123
1012 T. Ohrlander et al.: Morphological State as a Predictor

Table 2 Severity of morphological state in patients with AAA Table 3 Reinterventions during follow-up
scheduled for EVAR
Reinterventions (n)
Anatomical factors Percentage of patients
Endovascular
Aortic neck length (mm) Stenting/stentgrafting and PTA
[25 54.8 Stenting of the stentgraft limbs in the iliac arteries 21
15–25 40.2 Stenting/stentgrafting of the renal artery 15
10–14 3.6 Stenting/stentgrafting of the external iliac artery 12
\10 1.4 Re-stentgrafting and distal extension of the limb 10
Aortic neck diameter (mm) Re-stentgrafting and proximal extension of the main body 7
\24 53.5 Re-EVAR 5
24–25 21.1 Fenestrated stentgraft 5
26–28 20.1 Restenting and proximal fixation of the main body 4
[28 5.3 Stenting of common iliac artery 4
Aortic neck angle ( Æ , a) Branched stentgraft into the internal and external iliac artery 2
\30 21.6 Thorakal stentgraft 1
30–45 35.8 Stenting of the common femoral artery 1
46–60 21.1 Stentgrafting of the superior mesenteric artery 1
[60 21.6 PTA of a renal artery stent 2
Aortic aneurysm maximum diameter (cm) PTA of a stentgraft limb 1
4.0–5.4 31 Embolization
5.5–6.4 38 Aneurysmal sac 12
C6.5 31 Internal iliac artery 8
Common iliac artery maximum diameter (mm) Lumbal arteries 4
\12.5 5.3 Inferior mesenteric artery 3
12.5–14.5 10.7 Renal artery 1
14.6–17 19.6 Miscellaneous
[17 64.4 Intra-aneurysmal sac pressure measurements 3
Iliac artery maximum angulation (°, b) Thrombin injection into common femoral pseudoaneurysm 2
0–20 1.5 Thrombolysis for occluded stentgraft limb 1
21–59 14.1 Aorto-iliac angiography 1
60–90 66.7 Measurement of mean arterial pressure gradient 1
[90 17.7 Open
External iliac artery minimum diameter (mm) Main procedures
[10 7.3 Thrombectomy of stentgraft 7
9–10 33 Thrombendarterectomy/repair of the femoral arteries 7
7–8 45.5 Femoral—femoral crossover by-pass 5
\7 14.1 Open AAA repair (conversion) 4
Grading and categorization was modified after Chaikof et al. [11] Reoperation for pseudoaneurysm/bleeding at the femoral 4
access site
Reoperation for stentgraft infection
Small bowel reconstruction due to aorto-enteric fistula 4
Resection of aneurysm sac and omentoplasty 3
external iliac artery (trend; p = 0.053) were associated
Extirpation of parts of stentgraft 3
with an increased number of reinterventions in the uni-
Axillo-bifemoral by-pass 2
variate analysis. When entering these four variables in a
Percutaneous drainage of abscesses 2
Cox regression analysis, only a greater diameter of the
common iliac artery (p = 0.037; HR 1.037 [1.002–1.073]) Aorto-iliac reconstruction with prosthesis 1
remained as an independent factor for an increased number Ureterectomy due to aorto-ureteric fistula 1
of reinterventions. There was a trend that severity of Splenectomy 1
angulation of the proximal neck was found to be associated Miscellaneous
with an increased number of reinterventions (p = 0.065; Explorative laparotomy for assessing the severity of 2
intestinal ischemia
HR 1.013 [95% CI 0.999–1.027]).

123
T. Ohrlander et al.: Morphological State as a Predictor
Table 3 continued
Reinterventions
Colonic resection and sigmoidostomy
Thrombectomy of the common femoral artery
Thrombectomy of the popliteal artery
Surgical revision due to perivascular groin infection
Small-bowel resection
Reoperation for bleeding after open conversion
Reoperation for occluded femoral-femoral crossover bypass
Transposition of internal to external iliac artery
Fasciotomy
Aneurysm-Related and All-Cause Mortality
The 30-day mortality rate was 3.0% (9/304). The nine
EVAR-related early deaths were caused by: acute myo-
cardial infarction (n = 4), multiple organ failure (n = 3),
incarcerated scrotal hernia with intestinal infarction and
perforation (n = 1), and intestinal ischemia (n = 1). There
were six EVAR-related late deaths, which occurred due to
aorto-enteric fistula (n = 2), rupture (n = 2), stentgraft
infection (n = 1), and conversion to open AAA repair due
to stentgraft infection (n = 1). Aneurysm-related deaths
due to AAA occurred in 4.9% (15/304) of the patients. Five
patients died due to a concomitant ruptured thoracic aortic
aneurysm. The mortality until end of follow-up was 54.3%
(165/304). The crude all-cause mortality rate at 1, 3, and
5 years was 8.2%, 22.4%, and 34.9%, respectively. The
proportion of deaths caused by cardiovascular or vascular
diseases was 61.6%.
Patient and Aorto-Iliac Characteristics in Relation
to All-Cause Mortality
Among the variables tested in Table 1, higher age (p \
0.001), lower GFR (p \ 0.001), anemia (p = 0.001), and
in Table 2, the length of the proximal neck (p = 0.001),
severity of angulation of the iliac arteries (trend; p =
0.069) and a lesser diameter of the external iliac artery
(trend; p = 0.072) were found to be associated with mor-
tality in the univariate analysis. There was an association
between the severity of angulation of the iliac arteries and
mortality caused by vascular disease (trend; p = 0.071).
When entering these six variables in a Cox regression
analysis, only the severity of angulation of the iliac arteries
(p = 0.014; HR 1.018 [95% CI 1.004–1.033]) and anemia
(p = 0.044; HR 2.79 [95% CI 1.029–7.556]) remained as
independent factors associated with mortality. There was
no association between reintervention rate and mortality,
after entering age as a covariate (HR 1.233; 95% CI
[0.842–1.805]). The crude reintervention-free survival rate
1013
(n)
2
1
1
1
1
1
1
1
1
Fig. 2 Ten-year reintervention-free survival curve for patients who
underwent standard EVAR for AAA. Numbers below time axis
denotes patients at risk at respective time point. The tick marks
indicate censored data
at 1, 3, and 5 years was 84.5%, 64.8%, and 51.6%,
respectively. The Kaplan–Meier curve shows the reinter-
vention free survival rate during the long follow-up period
(Fig. 2).
Discussion
The initial aorto-iliac morphological state was highly
associated with both reintervention rate and all-cause
mortality during this long-term study. Not unexpectedly, a
greater diameter of the common iliac artery and the
severity of angulation of the proximal neck in the present
study were predictors for increased need of reintervention.
It is known that dilatation of one or both common iliac
arteries [4, 5] and short [6] and severe angled proximal
aortic necks may be present up to 40% of the cases,
respectively, to such an extent that the success of EVAR
will be compromised [7]. The single most common rein-
tervention procedure in this study was stenting of the limb
due to underlying kinking of the metallic skeleton. The
presentation of these patients with limb kinking often is
symptomatic [8] and progression toward limb occlusion is
not that rare, which has questioned the durability of the
ZenithÒ endoprosthesis [9, 10]. The severity of angulation,
calcification, and occlusive disease of the iliac arteries has
been documented previously to be associated with failure
of stentgraft deployment and, subsequently, a risk factor
for mortality [11]. Interestingly, severity of angulation in
the present study also was found to be independently
123
1014
associated with all-cause long-term mortality and mortality
caused by vascular disease. It is therefore suggested that
severity of angulation of the iliac arteries may be seen as an
indicator for advanced coronary and general atherosclero-
sis and mortality. The preoperative maximal aneurysm
diameter also has been found to be associated with
increased rates of aneurysm-unrelated deaths [12]. Hence,
it is reasonable to believe that patients with advanced
aorto-iliac morphological changes due to AAA and patients
requiring fenestrated stentgrafts [13] have a shorter sur-
vival benefit after EVAR than patients treated with stan-
dard stentgrafts.
Two ruptures of the AAA did occur during follow-up
after EVAR, and somewhat annoyingly, five patients died
unexpectedly due to a ruptured thoracic aortic aneurysm. A
recent study has reported that one-fourth of patients with
AAA also has a thoracic aortic aneurysm [14], implying
that the CT scan in the initial preoperative workup phase
should include the whole aorta. The overall early (30-day
postoperative mortality) and late aneurysm-related death
from AAA in the present study was 4.9% during the
6.5 year follow-up, somewhat lower compared with the
results in the EVAR trial [15]. Mortality increased signif-
icantly during mid- and long-term in the present study,
mainly due to associated comorbidities, leading to a rather
low, 52%, crude reintervention-free survival rate at
5 years, which is approximately similar to the ZenithÒ-
specific outcome from the EVAR 1 trial [16]. Medical
comorbidity severity, based on cardiac, pulmonary or renal
failure [11], and age, have been held responsible for the
late mortality in patients with AAA. Unexpectedly, anemia
was found in a high proportion of the study patients, 35%,
and was, somewhat surprisingly, the only independent
medical factor associated with all-cause mortality. We
therefore agree with Diehm and colleagues that the pres-
ence or absence of anaemia should be included in every
risk stratification model before EVAR [17].
The limitation of the present study was attributed to
the somewhat retrospective design in that complementary
data were retrieved from patient records. The aorto-iliac
morphological assessments were not performed on a
workstation with modern software-assisted programs for
three-dimensional computer-based intraluminal centerline
measurements [18]. Determination of aorto-iliac tortuosity
was therefore considered to be inappropriate with the study
method and the severity of angulation of the iliac arteries
should be considered as rough estimates. Nevertheless, the
morphological characteristics in the present study were
evaluated prospectively in the same manner in all patients
by the same observer. The influence of aorto-iliac mor-
phological state assessed with the three-dimensional cen-
terline method on long-term reintervention rate and
mortality needs to be addressed in future studies. The
123
T. Ohrlander et al.: Morphological State as a Predictor
initial aorto-iliac morphological state in patients scheduled
for standard EVAR for AAA seems to be strongly related
to the need for reinterventions and long-term mortality.
Conflict of interest The authors declare no conflict of interest.
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