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We read with great interest the article by Mazzaccaro et al. (1) reporting on early results of ultra-low profile endografts, for which the authors should be congratulated. In quest of broadening the instructions-for-use range of endografts to treat abdominal aortic aneurysms (AAA), current modifications focus on down-sizing the delivery profiles, thus enabling passage and navigation not only through narrower iliac vessels, but confronting also highly angulated and/or tortuous vessels successfully (2). The INNOVATION trial reported very satisfactory results in the 4-year follow-up of 60 patients; however, only a minority (7%) of patients presented with severe iliac tortuosity (3). Admittedly, in current “real-world” practice many clinicians tend to use other well-established endografts that they are more familiar with, reserving the novel ultra-low profile devices for AAA of challenging iliac anatomies, as described above. A recent review by Mantas et al. (4) identified the presence of significant angulation and calcification of the iliac arteries as well as excessive limb oversizing as independent predictors of endograft limb occlusion after endovascular aneurysm repair (4). Therefore, although most physicians’ preference support the use of ultra-low profile endografts in such cases, we would strongly advocate the routine use of a balloon-expandable stent support to avoid compression of the iliac limbs in cases of tight aortic bifurcation or severe iliac angulation/tortuosity, as illustrated in the example (Fig.). We believe that this strategy would further guarantee the long-term clinical efficacy of ultra-low endografts in challenging iliac anatomies.

diagnostic and interventional radiology

Use of balloon-expandable stents to support the efficacy of ultra-low profile endografts in the treatment of abdominal aortic aneurysms with challenging iliac anatomy