Endovascular treatment of abdominal aortic aneurysms with the Powerlink Endograft System: influence of placement on the bifurcation and use of a proximal extension on early and late outcomes.

Objective: We evaluated the influence of placement of the bifurcated Powerlink endograft (Endologix Inc, Irvine, Calif)on the aortic bifurcation, with the addition of a proximal extension, in the endovascular treatment (EVAR) of selectedpatients with atherosclerotic abdominal aortic aneurysms (AAAs).Methods: From September 1999 to June 2007, 205 patients were treated with the bifurcated Powerlink endograft foratherosclerotic AAA at two Italian centers with shared protocols. Patients were retrospectively divided in two groupsaccording to treatment with the bifurcated graft only (n 126), or its placement on the bifurcation with the addition ofa proximal extension (n 79) at the initial procedure. Study end points included postoperative complications, secondaryprocedures, immediate and late conversion, migration, endoleak, death, and aneurysmal sac behavior.Results: Overall technical success was 98.5%. Additional procedures were performed in 18%, and postoperative complicationsoccurred in 11.2% (systemic, 8.3%; local, 2.9%). Median follow-up was 42.4 months (range, 6-94 months).Secondary procedures were recorded in 11.2%, migration in 3.9%, type I proximal endoleak in 7.8%, and late conversionsin 2.4%. Placement on the bifurcation and the addition of an extension were associated with a higher incidence ofpostoperative complications (7.1% vs 17.7%, P .020). A reduced incidence of endoleak (19% vs 8.9%, P .048),secondary procedures (14.3% vs 6.3%, P .04), and migration (6.3% vs 0%, P .024) were observed in the group witha proximal extension. Analysis of single variables reveals that migration was significantly influenced by placement of thegraft on the bifurcation (47% vs 0%, P < .001). Both placement on the bifurcation and the addition of an extensionpositively influenced the type I proximal endoleak rate (3.8% vs 35.3% P < .001) and the need for a secondary intervention(6.3% vs 35.3% P < .001) Two aneurysm ruptures and five cases of late conversion occurred in the group treated with abifurcated graft only (4%, P .52, P .159). Analysis of aneurysm sac behavior was not statistically significant:enlargement, 4.1% vs 1.3% (P .158); reduction, 34.1% vs 40.5% (P .542).Conclusion: The placement of the bifurcated Powerlink endograft on the aortic bifurcation with a proximal extension forcomplete sealing seems to improve late outcomes, particularly secondary procedures, migration, and endoleak development.Larger prospective studies with longer follow-up are necessary to confirm these promising results.