High-risk neck features continue to present challenges for endovascular infrarenal aneurysm repair. In this issue of the Journal of Vascular Surgery Cases, Innovations, and Techniques, Germano et al1 describe the circumferential, simultaneous deployment of endostaples in the proximal seal zone as a prophylactic fixation adjunct designed to mimic a handsewn anastomosis in an aneurysm with a short neck. The patient in their case report is part of SEAL (Safety & Feasibility evaluation of the Aortoseal),2 which seeks to establish feasibility of the endostaple Aortoseal fixation approach.
Adjuncts for proximal fixation have been an active area of innovation since at least the time of ANCHOR (Aneurysm Treatment using the Heli-FX Aortic Securement System Global Registry) in 2014,3 which characterized the performance of endoanchors in primary and revision endovascular aneurysm repairs. More recently, endoanchors were compared favorably with custom fenestrated endografts for juxtarenal aneurysms with short necks,4 providing an off-the-shelf option with similar rates of sac regression, type Ia endoleak, and aneurysm-associated mortality. Endoanchors in the infrarenal aorta have been shown to be safe, but the indication for which endoanchors would be the most clearly useful—in repairing existing type Ia endoleaks—is the also where they are the least successful.5,6 Although Germano et al can be commended for an early description of technically sound deployment of a novel device, the neck characteristics that would clearly stand to benefit from adjunctive fixation with an additional device are not defined clearly.
Questions about cost, durability, radiation exposure, and potential complications of inadequately deployed endostaples should be answered by the SEAL trial. The SEAL trial, however, may not be equipped to answer definitively whether young patients with questionable aortic neck anatomy would be better served by index open repair. Ultimately, thoughtful evaluation and dissemination of early experiences with novel technologies such as the Aortoseal are central to the mission of the Journal of Vascular Surgery Cases, Innovations and Techniques. Highlighting these early advances fosters informed dialogue, guides subsequent trial design, and helps to define where new technologies may complement existing open and endovascular therapies to improve patient-centered vascular care.
The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery Cases and Innovative Techniques or the Society for Vascular Surgery.
Funding
None.
Disclosures
None.
Footnotes
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
References
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