ERI in action: Assess type 1A Endoleak risk index before the intervention
Clinical Context
A complex EVAR case was presented by Dr. Nilo J. Mosquera (Hospital Santiago de Compostela, Spain) involving a hostile proximal aortic neckβshort (9 mm), angulated, and conicalβan anatomy known to increase the risk of Type IA endoleak. Standard sizing alone was insufficient to confidently predict sealing performance. The key question was whether a 32 mm or 36 mm endograft would provide an adequate proximal seal without increasing the risk of Type IA endoleak in this highβrisk anatomy.
Case Overview: A Hostile Proximal Neck
The patient presented with a challenging proximal aortic neck characterized by multiple highβrisk features:
- Very short proximal neck (9 mm)
- Angulated and conical morphology
- Multiple risk factors for disease progression
- Absence of significant calcification
While the anatomy was clearly hostile, it remained within the instructions for use (IFU) for EndoSuture Aneurysm Repair (ESAR), keeping EVAR as a viable option. However, the key question remained: how high was the true risk of a Type IA endoleak, and how should it influence graft selection?
ERI Simulation: 32 mm vs 36 mm Endograft
To support decisionβmaking, ERI simulations were performed comparing two potential main body sizes: 32 mm and 36 mm.
The ERI analysis revealed a high likelihood of Type IA endoleak for both configurations, with particular concern noted for the 36 mm endograft. These findings highlighted that oversizing alone would not mitigate risk in this anatomy and that sealing behavior needed to be anticipated beyond standard sizing rules.
Rather than replacing clinical judgment, ERI added a new layer of insightβquantifying risk before entering the operating room.
Clinical Strategy: Planning for Risk, Not Reacting to It
After reviewing the ERI results, Dr. Nilo J. Mosquera elected to proceed with implantation of a 36 mm Endurant endograft combined with EndoAnchors, proactively planning for ESAR.
This strategy acknowledged the elevated risk predicted by ERI and ensured that a solution was immediately available should a Type IA endoleak occur intraoperatively.