Reducing complications by better case selection: anatomic considerations.

The feasibility of endovascular aortic aneurysm repair (EVAR) in any individual patient remains inherently dependent on the anatomy of the aorta and iliac arteries. There is a great deal of evidence in the literature that poor anatomic patient selection for EVAR will increase the risk of both procedure-related complications and compromised long-term outcomes. Inferior outcomes can include technical failures such as attachment-site endoleak, endograft migration, and ultimately aneurysm growth and rupture. Unfortunately, it is relatively rare to encounter a patient who possesses completely "ideal" anatomy for this technique. With the broadening spectrum of new devices applicable for the intraluminal treatment of abdominal aortic aneurysms, the vascular surgeon is challenged to be aware of individual selection criteria for the ever-widening variety of endoluminal grafts, in order to choose the optimal device for each patient's distinct anatomical situation. In patients who would otherwise be at high risk for traditional abdominal aortic aneurysm surgery based on medical comorbidities, the additional challenge for the practitioner who performs EVAR is to possess excellent judgment regarding just how far the anatomical "envelope" may be pushed without compromising patient outcomes.