Despite continuous advancement in endovascular technologies, challenging aortic anatomy, including hostile proximal aortic necks, anatomically smaller iliac arteries, iliac occlusive disease, iliac artery stenosis and difficult access vessels still limit the applicability of endovascular aortic aneurysm exclusion (EVAR), with conventional devices, in patients affected by abdominal aortic aneurysm (AAA). The advent of ultra low-profile (ULP) endograft with a 14 F outer diameter has allowed the feasibility of EVAR of infrarenal AAA in patients who have previously been excluded because of challenging aortic anatomies and small and tortuous access vessels. Among the devices now available, the ultra-low-profile endografts Ovation (Endologix, Santa Rosa, Calif) and INCRAFT (Cordis Corp., Milpitas, Calif) have been shown as safe and effective in patients with heavily calcific external and common iliac axes, or with aortoiliac occlusive disease. The purpose of this study is to compare the long-term follow-up of these two endoprosthesis.

This is a a single-center, retrospective evaluation of 102 patients between 2012 and 2019 that underwent elective EVAR with ultra-low profile endograft (Cordis Incraft and Endologix Ovation). The selection of EVAR graft considered the anatomical characteristics of the aortic neck and of the iliac arteries, the presence of thrombus or calcification and the small and tortuous iliac vessels or iliac occlusive disease or iliac artery stenosis. Follow-up data were analyzed to evaluate success, survival, complications, and device-related events, both at 30 days and in the long-term. The success was defined as successful access, delivery and implant of the endograft with absence of immediate surgical conversion, mortality, endoleak, or graft limb occlusion. Postoperative surveillance protocol included a duplex ultrasonography (DUS) scan at discharge, at 1, 6, and 12 months, and annually thereafter. A CTA was performed at 1 months and in case of non-diagnostic DUS scan or if either graft thrombosis or endoleak was suspected at DUS scan.

The two groups were different in terms of aorto-iliac anatomy, as patients of group Ovation had a proximal aortic neck which was affected by a greater presence of thrombus (percentage of the circumference covered by thrombus: 47,4 vs. 12,7 p <0.001). All of the Ovation endografts were implanted by bilateral percutaneous femoral access and the Incraft endograft bilateral percutaneous femoral access were 91,6%. At 30 days follow up at the Incraft group, 1 patient underwent re-intervention, none in the Ovation group. A significant difference in the incidence of postimplantation syndrome was recorded after the use of the Incraft endograft compared with the Ovation graft (14% vs. 0%, p=0.009). The long-term follow-up mean was 54,37 +/- 30,5 months for the Ovation and 32,47 +/- 19,4 for the Cordis Incraft group. Endoleak was present in 20% and 13% respectively. One patient in the Ovation group underwent endograft explant for endoleak IA. In the Incraft group, 10,5% of patients underwent reintervention for: embolization, relining, thromboaspiration under the knee and Chimney technique. At the follow up, the Ovation group presented 37,8% of patients death and 15,8% in the Incraft group.

Both ultra-low profile endografts showed good mid and long-term follow-up outcomes. The selection of the prosthesis is important to avoid complications. Bilateral femoral percutaneous access is the preferred technique without major complications and good results.