{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T03:01:40Z","timestamp":1787022100310,"version":"build-2736575974"},"reference-count":33,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2022,2,24]],"date-time":"2022-02-24T00:00:00Z","timestamp":1645660800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>A growing number of abdominal aortic aneurysms with severe angulated neck anatomy is treated by endovascular means. However, contradictory early and late outcomes have been reported. Our review and outcome analysis attempted to evaluate the available literature and provide clinicians with a base for clinical implementation and future research.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Materials and methods<\/jats:title>\n                    <jats:p>\n                      A systematic review of the literature was undertaken to identify the outcomes of endovascular aneurysm repair in patients with severe infrarenal neck angulation (SNA\n                      <jats:bold>\u2265<\/jats:bold>\n                      60\u00b0) vs non-severe neck angulation (NSNA). Outcome measures included perioperative complications, type 1a endoleak, neck-related secondary procedures, stent graft migration, aneurysm rupture, increase (&gt;5mm) in sac diameter, all-cause and aneurysm-related mortality (PROSPERO Nr.: CRD42021233253).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Six observational studies reporting on 5981 patients (1457 with SNA and 4524 with NSNA) with a weighted mean follow-up period of 1.8 years were included. EVAR in SNA compared with NSNA was associated with a higher rate of type 1a endoleak at 30 days (4.0%\n                      <jats:italic>vs<\/jats:italic>\n                      1.8%; p&lt; 0.00001), at 1 year (2.8%\n                      <jats:italic>vs<\/jats:italic>\n                      1.9%; p&lt;0.03), at 2 years (4.9%\n                      <jats:italic>vs<\/jats:italic>\n                      2.1%; p&lt; 0.0002), at 3 years (5.6%\n                      <jats:italic>vs<\/jats:italic>\n                      2.6%; p&lt; 0.0001). The rate of neck-related secondary procedures was significantly higher at 1 year (6.6% vs 3.9%; p&lt;0.05) and at 3 years (13.1% vs 9%; p&lt;0.05). Graft migration, aneurysm sack increase, aneurysm rupture and all-cause mortality were not statistically different at mid-term.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The use of EVAR in severely angulated infrarenal aortic necks is associated with a high rate of early and mid-term complications. However, aortic related and all-causes mortality are not higher compared to patients with NSNA. Therefore, EVAR should be cautiously used in patients with SNA.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0264327","type":"journal-article","created":{"date-parts":[[2022,2,24]],"date-time":"2022-02-24T13:44:13Z","timestamp":1645710253000},"page":"e0264327","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":20,"title":["A meta-analysis of safety and efficacy of endovascular aneurysm repair in aneurysm patients with severe angulated infrarenal neck"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8731-0954","authenticated-orcid":true,"given":"Giulia","family":"Bernardini","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0317-8782","authenticated-orcid":true,"given":"Sarah","family":"Litterscheid","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni Battista","family":"Torsello","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni Federico","family":"Torsello","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Efthymios","family":"Beropoulis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denise","family":"\u00d6zdemir-van Brunschot","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2022,2,24]]},"reference":[{"issue":"4","key":"pone.0264327.ref001","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1053\/j.semvascsurg.2012.09.001","article-title":"The proximal neck: the remaining barrier to a complete EVAR world.","volume":"25","author":"JP de Vries","year":"2012","journal-title":"Semin Vasc Surg."},{"issue":"1","key":"pone.0264327.ref002","first-page":"60","article-title":"Hostility of proximal aortic neck anatomy in relation to abdominal aortic aneurysm size and its impact on the outcome of endovascular repair with the new generation endografts.","volume":"61","author":"C Karathanos","year":"2020","journal-title":"J Cardiovasc Surg (Torino)"},{"issue":"6","key":"pone.0264327.ref003","doi-asserted-by":"crossref","first-page":"841","DOI":"10.1583\/14-4795MR.1","article-title":"Midterm results of endovascular aneurysm repair using the Endurant stent-graft according to the instructions for use vs. off-label conditions","volume":"21","author":"N Troisi","year":"2014","journal-title":"J Endovasc Ther."},{"issue":"4","key":"pone.0264327.ref004","doi-asserted-by":"crossref","first-page":"885","DOI":"10.1016\/j.jvs.2014.04.063","article-title":"Aneurysm Treatment using the Heli-FX Aortic Securement System Global Registry (ANCHOR) Workgroup Members. Results of the ANCHOR prospective, multicenter registry of EndoAnchors for type Ia endoleaks and endograft migration in patients with challenging anatomy","volume":"60","author":"WD Jordan","year":"2014","journal-title":"J Vasc Surg"},{"issue":"6","key":"pone.0264327.ref005","doi-asserted-by":"crossref","first-page":"1699","DOI":"10.1016\/j.jvs.2017.10.059","article-title":"Matched cohort comparison of endovascular abdominal aortic aneurysm repair with and without EndoAnchors","volume":"67","author":"BE Muhs","year":"2017","journal-title":"J Vasc Surg"},{"issue":"6","key":"pone.0264327.ref006","doi-asserted-by":"crossref","first-page":"683","DOI":"10.1177\/1708538120924552","article-title":"Early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between severe and non-severe infrarenal neck angulation.","volume":"28","author":"K Chinsakchai","year":"2020","journal-title":"Vascular"},{"issue":"1","key":"pone.0264327.ref007","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1583\/06-1914.1","article-title":"Buth J; EUROSTAR Collaborators. Influence of severe infrarenal aortic neck angulation on complications at the proximal neck following endovascular AAA repair: a EUROSTAR study.","volume":"14","author":"R Hobo","year":"2007","journal-title":"J Endovasc Ther."},{"issue":"5","key":"pone.0264327.ref008","doi-asserted-by":"crossref","first-page":"668","DOI":"10.1007\/s00270-015-1260-7","article-title":"Evaluation of Aneurysm Neck Angle Change After Endovascular Aneurysm Repair Clinical Investigations","volume":"39","author":"TB Le","year":"2016","journal-title":"Cardiovasc Intervent Radiol."},{"issue":"6","key":"pone.0264327.ref009","doi-asserted-by":"crossref","first-page":"1598","DOI":"10.1016\/j.jvs.2016.10.120","article-title":"Five-year outcomes of the PYTHAGORAS U.S. clinical trial of the Aorfix endograft for endovascular aneurysm repair in patients with highly angulated aortic necks","volume":"65","author":"MB Malas","year":"2017","journal-title":"J Vasc Surg"},{"issue":"6","key":"pone.0264327.ref010","doi-asserted-by":"crossref","first-page":"1881","DOI":"10.1016\/j.jvs.2019.07.096","article-title":"A comparison of clinical outcomes of abdominal aortic aneurysm patients with favorable and hostile neck angulation treated by endovascular repair with the Treovance stent graft","volume":"71","author":"D Murray","year":"2020","journal-title":"J Vasc Surg"},{"issue":"6","key":"pone.0264327.ref011","doi-asserted-by":"crossref","first-page":"1725","DOI":"10.1016\/j.jvs.2018.03.427","article-title":"Long-term outcomes of standard endovascular aneurysm repair in patients with severe neck angulation","volume":"68","author":"NFG Oliveira","year":"2018","journal-title":"J Vasc Surg"},{"key":"pone.0264327.ref012","doi-asserted-by":"crossref","first-page":"b2700","DOI":"10.1136\/bmj.b2700","article-title":"The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration","volume":"339","author":"A Liberati","year":"2009","journal-title":"BMJ"},{"key":"pone.0264327.ref013","unstructured":"Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org."},{"key":"pone.0264327.ref014","unstructured":"Wells GA, Shea B, O\u2019Connell D, Peterson J, Welch V, Losos M et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at: http:\/\/www.ohri.ca\/programs\/clinical_epidemiology\/oxford.asp. Accessed June 21, 2012."},{"key":"pone.0264327.ref015","doi-asserted-by":"crossref","first-page":"1048","DOI":"10.1067\/mva.2002.123763","article-title":"Ad Hoc Committee for Standardized Reporting Practices in Vascular Surgery of the Society for Vascular Surgery. Reporting standards for endovascular aortic aneurysm repair","volume":"35","author":"EL Chaikof","year":"2002","journal-title":"J Vasc Surg"},{"key":"pone.0264327.ref016","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1016\/0197-2456(86)90046-2","article-title":"Meta-analysis in clinical trials.","volume":"7","author":"R DerSimonian","year":"1986","journal-title":"Control Clin Trials"},{"issue":"1","key":"pone.0264327.ref017","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.ejvs.2018.09.020","article-title":"2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms","volume":"57","author":"A Wanhainen","year":"2019","journal-title":"Eur J Vasc Endovasc Surg"},{"key":"pone.0264327.ref018","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1016\/j.avsg.2019.05.049","article-title":"Expert opinion on hostile neck definition in endovascular treatment of abdominal aortic aneurysms (a Delphy consensus)","volume":"62","author":"EM Marone","year":"2020","journal-title":"Ann Vasc Surg."},{"issue":"2","key":"pone.0264327.ref019","doi-asserted-by":"crossref","first-page":"93","DOI":"10.2310\/6670.2010.00010","article-title":"Early and late clinical outcomes of endovascular aneurysm repair in patients with an angulated neck.","volume":"18","author":"AF AbuRahma","year":"2010","journal-title":"Vascular"},{"issue":"1","key":"pone.0264327.ref020","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1016\/j.jvs.2014.06.104","article-title":"2nd. Remodeling of aortic aneurysm and aortic neck on follow-up after endovascular repair with suprarenal fixation","volume":"61","author":"N Tsilimparis","year":"2015","journal-title":"J Vasc Surg"},{"issue":"2","key":"pone.0264327.ref021","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1016\/j.jvs.2012.09.050","article-title":"A meta-analysis of outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile and friendly neck anatomy","volume":"57","author":"GA Antoniou","year":"2013","journal-title":"J Vasc Surg"},{"issue":"3","key":"pone.0264327.ref022","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1016\/j.jvs.2011.03.235","article-title":"Early results of the Endurant endograft system in patients with friendly and hostile infrarenal abdominal aortic aneurysm anatomy","volume":"54","author":"GS Georgiadis","year":"2011","journal-title":"J Vasc Surg"},{"issue":"5","key":"pone.0264327.ref023","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1583\/09-2822.1","article-title":"The Aorfix stent-graft to treat infrarenal abdominal aortic aneurysms with angulated necks and\/or tortuous iliac arteries: midterm results","volume":"16","author":"T Perdikides","year":"2009","journal-title":"J Endovasc Ther"},{"issue":"8","key":"pone.0264327.ref024","doi-asserted-by":"crossref","first-page":"1012","DOI":"10.1016\/j.avsg.2010.08.013","article-title":"Long-Term Influence of Suprarenal or Infrarenal Fixation on Proximal Neck Dilatation and Stentgraft Migration After EVAR","volume":"25","author":"D Pintoux","journal-title":"Annals of Vascular Surgery"},{"issue":"6","key":"pone.0264327.ref025","doi-asserted-by":"crossref","first-page":"726","DOI":"10.1177\/1526602818803939","article-title":"Global Post-Market Clinical Follow-up of the Treovance Stent-Graft for Endovascular Aneurysm Repair: One-Year Results From the RATIONALE Registry","volume":"25","author":"R Uberoi","year":"2018","journal-title":"J Endovasc Ther."},{"key":"pone.0264327.ref026","first-page":"175e181","article-title":"Editor\u2019s Choice e Five Year Outcomes of the Endurant Stent Graft for Endovascular Abdominal Aortic Aneurysm Repair in the ENGAGE Registry","volume":"58","author":"JAW Teijink","year":"2019","journal-title":"Eur J Vasc Endovasc Surg"},{"issue":"6","key":"pone.0264327.ref027","doi-asserted-by":"crossref","first-page":"1495","DOI":"10.1016\/j.jvs.2013.12.034","article-title":"Results of the Anaconda\u2122 endovascular graft in abdominal aortic aneurysm with a severe angulated an infrarenal neck","volume":"59","author":"SGJ R\u00f6del","year":"2014","journal-title":"J Vasc Surg"},{"key":"pone.0264327.ref028","first-page":"1","article-title":"Technical success and outcomes using a flexible bifurcated stent graft (Aorfix TM) in abdominal aortic aneurysms: a systematic review","author":"A Khan","year":"2021","journal-title":"Expert Rev Med Devices."},{"issue":"3","key":"pone.0264327.ref029","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1016\/j.jvscit.2019.03.014","article-title":"Initial human experience with the GORE EXCLUDER Conformable AAA Endoprosthesis","volume":"5","author":"R Rhee","year":"2019","journal-title":"J Vasc Surg Cases Innov Tech"},{"key":"pone.0264327.ref030","first-page":"152660281983731","article-title":"Chimney Endovascular Aneurysm Repair Using Endurant Stent-Grafts With Bare Balloon-Expandable Stents for Patients With Juxtarenal Aortic Aneurysms","author":"N. Morikage","year":"2019","journal-title":"Journal of Endovascular Therapy"},{"issue":"1","key":"pone.0264327.ref031","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.jvs.2016.12.117","article-title":"Predictors of early aortic neck dilatation after endovascular aneurysm repair with EndoAnchors","volume":"66","author":"AK Tassiopoulos","year":"2017","journal-title":"J Vasc Surg"},{"key":"pone.0264327.ref032","article-title":"Multicenter registry about the use of EndoAnchors in the endovascular repair of abdominal aortic aneurysms with hostile neck showed successful but delayed endograft sealing within intraoperative type IA endoleak cases","author":"A. R. Valdivia","year":"2019","journal-title":"Annals of Vascular Surgery"},{"issue":"7","key":"pone.0264327.ref033","doi-asserted-by":"crossref","first-page":"971","DOI":"10.1007\/s00270-020-02488-4","article-title":"Improved Midterm Outcomes Using Standard Devices and EndoAnchors for Endovascular Repair of Abdominal Aortic Aneurysms with Hyperangulated Necks","volume":"43","author":"A Chaudhuri","year":"2020","journal-title":"Cardiovasc Intervent Radiol."}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0264327","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,2,24]],"date-time":"2022-02-24T13:44:54Z","timestamp":1645710294000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0264327"}},"subtitle":[],"editor":[{"given":"Athanasios","family":"Saratzis","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2022,2,24]]},"references-count":33,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2022,2,24]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0264327","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,2,24]]}}}