The Hostile Neck

The treatment of complex thoracic and aortic aneurysms with hostile necks represents a major challenge compared to that with friendly neck anatomy. To date, the available therapeutic options including open and endovascular techniques have no true algorithm for the use in hostile anatomies, and surgeons worldwide lack clinical strategies and insights on how to expand current treatment options to more challenging cases.


This dedicated homepage aims to collate the current literature on this topic, and also seeks to bring the vascular community closer together to ensure optimal patient care and improved outcomes in this patient population. I hope that this time-saving resource will help like-minded physicians to learn more and interact on this topic. I also invite you to share and present your experience and cases in this section or through our dedicated journal, Vascular and Endovascular Review which is indexed in Scopus and the Directory of Open Access Journals (DOAJ).

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Prof Konstantinos Donas

Section Advisor

Prof Konstantinos Donas

Head of the Department of Vascular Surgery, Director of the Research Vascular Centre, Asklepios Clinic Langen, University of Frankfurt, Germany

The Radcliffe Hostile Neck educational hub is an independent program led by Prof K Donas.

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Endograft apposition and infrarenal neck enlargement after endovascular aortic aneurysm repair

van der Riet C, DE Rooy PM, Tielliu IF, et al. J Cardiovasc Surg (Torino) 2021;62:600–8.

Outcomes of elective use of the chimney endovascular technique in pararenal aortic pathologic processes

Pitoulias GA, Torsello G, Austermann M, et al. J Vasc Surg 2021;73:433–42.

Long-term chimney/snorkel endovascular aortic aneurysm repair experience for complex abdominal aortic pathologies within the PERICLES registry

Taneva GT, Lee JT, Tran K, et al. J Vasc Surg 2021;73:1942–9.

Impact of proximal neck anatomy on short-term and mid-term outcomes after treatment of abdominal aortic aneurysms with new-generation low-profile endografts

D'Oria M, Galeazzi E, Veraldi GF, et al. Ann Vasc Surg 2021; epub ahead of press.

Favorable outcomes in octogenarians with hostile neck undergoing endovascular repair using EndoAnchors

Locham S, Mathlouthi A, Dakour-Aridi H, Malas MB. Ann Vasc Surg 2021;74:194–203.

The role of surgical and total endovascular techniques in the treatment of ruptured juxtarenal aortic aneurysms

Keschenau PR, Beropoulis E, Gombert A, et al. Vasa 2021;50:356–62.

A five-year computed tomography follow-up study of proximal aortic neck dilatation after endovascular aortic repair using four contemporary types of endograft

Deltomme M, Van den Berge S, Mufty H, et al. Cardiovasc Intervent Radiol 2021;44:1384–93.

A multicenter "real-world" study of the valiant NAVION stent graft

Reyes-Valdivia A, Kratimenos T, Ferraresi M, et al. Int J Cardiol 2021;331:63–8.

Endovascular aortic repair in patients with challenging anatomies: the EXTREME study

Sirignano P, Mansour W, Capoccia L, et al. EuroIntervention 2021;16:e1544–50.

Determination of optimal and safest proximal sealing length during thoracic endovascular aortic repair

Piazza M, Squizzato F, Xodo A, et al. Eur J Vasc Endovasc Surg 2021;62:423–30.

The PROTAGORAS 2.0 study to identify sizing and planning predictors for optimal outcomes in abdominal chimney endovascular procedures

Fazzini S, Martinelli O, Torsello G, et al. Eur J Vasc Endovasc Surg 2021;61:591–602.

Editor's choice – mid term outcomes of crossed limb vs. standard limb configuration in endovascular abdominal aortic aneurysm repair: a propensity score analysis

Wang J, Zhao J, Ma Y, et al. Eur J Vasc Endovasc Surg 2021;61:579–88.

Risk factors, dynamics, and clinical consequences of aortic neck dilatation after standard endovascular aneurysm repair

Oliveira NFG, Oliveira-Pinto J, van Rijn MJ, et al. Eur J Vasc Endovasc Surg 2021;62:26–35.

Endurant stent graft demonstrates promising outcomes in challenging abdominal aortic aneurysm anatomy

Mwipatayi BP et al. J Vasc Surg. 2021 Jan;73(1):69-80.

Mid-Term Results of Endovascular Aneurysm Sealing in the Treatment of Abdominal Aortic Aneurysm With Unfavorable Morphology

Dzieciuchowicz Ł et al. Vasc Endovascular Surg. 2021 Jan;55(1):39-49.

Early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between severe and non-severe infrarenal neck angulation

Chinsakchai K et al. Vascular. 2020 Dec;28(6):683-691.

Early periaortic hematoma development after EVAR in the presence of severely calcified and modestly conical-shaped aortic neck: A potential trigger for sudden aneurysm progression toward rupture

De Santis F et al. Vascular. 2020 Dec 13:1708538120978030.

The Treovance aortic stent graft can confer advantage in dealing with the patient origin-related unfavorable abdominal aortic aneurysm anatomy

Georgakarakos E et al. J Vasc Surg. 2020 Dec;72(6):2213.

Factors affecting the occurrence of proximal endoleak after endovascular abdominal aortic repair for abdominal aneurysms

Mazzaccaro D et al. J Int Med Res. 2020 Nov;48(11):300060520971515.

Use of the Ovation Endograft System to Treat Abdominal Aortic Aneurysms With Hostile Anatomy

Morgan-Bates K et al. Eur J Vasc Endovasc Surg. 2020 Nov;60(5):786-787.

Morphologic Features of Symptomatic and Ruptured Abdominal Aortic Aneurysm in Asian Patients

Wang H et al. Ann Vasc Surg. 2020 Nov 4:S0890-5096(20)30932-8.

Long-term outcomes of the Ovation Stent Graft System investigational device exemption trial for endovascular abdominal aortic aneurysm repair

Barleben A et al. J Vasc Surg. 2020 Nov;72(5):1667-1673.e1.

Endograft Conformability in Fenestrated Endovascular Aneurysm Repair for Complex Abdominal Aortic Aneurysms

de Niet A et al. J Endovasc Ther. 2020 Oct;27(5):848-856.

The Effects of Gender on Radiation Dose during Fenestrated Endovascular Aneurysm Repair

Klein A et al. Ann Vasc Surg. 2020 Oct;68:305-309.

Mid-term outcomes of endovascular aneurysm repair in challenging aortic neck anatomy based on experience from the GREAT C3 registry

Sayed T et al. J Cardiovasc Surg (Torino). 2020 Oct;61(5):610-616.

Predictors of Aneurysm Sac Shrinkage Utilizing a Global Registry

Boutrous ML et al. Ann Vasc Surg. 2020 Sep 2:S0890-5096(20)30791-3.

LUCY results show females have equivalent outcomes to males following endovascular abdominal aortic aneurysm repair despite more complex aortic morphology

Ash J et al. J Vasc Surg. 2020 Aug;72(2):566-575.e4.

The Italian Multicentre Registry of Fenestrated Anaconda™ Endografts for Complex Abdominal Aortic Aneurysms Repair

Pini R et al. Eur J Vasc Endovasc Surg. 2020 Aug;60(2):181-191.

Sex-Related Outcomes After Endovascular Aneurysm Repair Within the Global Registry for Endovascular Aortic Treatment

Mwipatayi BP et al. Ann Vasc Surg. 2020 Aug;67:242-253.e4.

Five Year Results of the French EPI-ANA-01 Registry of Anaconda(TM) Endografts in the Treatment of Infrarenal Abdominal Aortic Aneurysms

Midy D et al. Eur J Vasc Endovasc Surg. 2020 Jul;60(1):16-25.

Outcomes after treatment of complex aortic abdominal aneurysms with the fenestrated Anaconda endograft

de Niet A et al. J Vasc Surg. 2020 Jul;72(1):25-35.e1.

One-Year Results From the SURPASS Observational Registry of the CTAG Stent-Graft With the Active Control System

Torsello GF et al. J Endovasc Ther. 2020 Jun;27(3):421-427.

Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms and safety of Suprarenal Aortic Clamping

Jeong S et al. World J Surg. 2020 Jun;44(6):2002-2009.

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

Murray D et al. J Vasc Surg. 2020 Jun;71(6):1881-1889.

Comparison of midterm results of endovascular aneurysm repair for ruptured and elective abdominal aortic aneurysms

Oliveira-Pinto J et al. J Vasc Surg. 2020 May;71(5):1554-1563.e1.

Systematic review with pooled data analysis reveals the need for a standardized reporting protocol including the visceral vessels during fenestrated endovascular aortic repair (FEVAR)

Karaolanis GI, Antonopoulos CN, Scali S, et al. Vascular 2021; epub ahead of press.

Experience with unfavorable iliac access when performing fenestrated/branched endovascular aneurysm repair

Hertault A, Bianchini A, Daniel G, et al. J Endovasc Ther 2021;28:315–22.

The polymer-based technology in the endovascular treatment of abdominal aortic aneurysms

de Donato G, Pasqui E, Panzano C, et al. Polymers (Basel) 2021;13:1196.

Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms

Elhelali A, Hynes N, Devane D, et al. Cochrane Database Syst Rev 2021;6:CD012923.

Endoluminal Management of Infra-renal Aortic and Aorto-iliac Aneurysms

Holden A et al. Cardiovasc Intervent Radiol. 2020 Dec;43(12):1788-1797.

An update on the ovation abdominal stent graft for the treatment of abdominal aortic aneurysms: current evidence and future perspectives

Georgakarakos E et al. Expert Rev Med Devices. 2020 Dec;17(12):1249-1256.

An update on the improvement of patient eligibility with the use of new generation endografts for the treatment of abdominal aortic aneurysms

Kontopodis N et al. Expert Rev Med Devices. 2020 Nov;17(11):1231-1238.

Endovascular Aortic Repair with the "Step-by-Step" Deployment of the Endurant Stent-Graft System in Severe Neck Angulation: Technique and Review of the Literature

Tasselli S et al. Ann Vasc Surg. 2020 Oct;68:553-558.

Outcomes of endosutured aneurysm repair with the Heli-FX EndoAnchor implants

Karaolanis G et al. Vascular. 2020 Oct;28(5):568-576.

Radial Access For Neurointerventions

Roger Barranco Pons, 2020

Similar 5-year outcomes between female and male patients undergoing elective endovascular abdominal aortic aneurysm repair with the Ovation stent graft

Varkevisser RRB et al. J Vasc Surg. 2020 Jul;72(1):114-121.

Improved Midterm Outcomes Using Standard Devices and EndoAnchors for Endovascular Repair of Abdominal Aortic Aneurysms with Hyperangulated Necks

Chaudhuri A et al. Cardiovasc Intervent Radiol. 2020 Jul;43(7):971-980.

Systematic review and meta-analysis of outcomes of open and endovascular repair of ruptured abdominal aortic aneurysm in patients with hostile vs. friendly aortic anatomy

Kontopodis N, Tavlas E, Ioannou CV, et al. Eur J Vasc Endovasc Surg 2020;59:717–28.

Next-Generation Conformable EVAR Device With 90o Angulated Aortic Neck

Sarah Eaton, 2018

Exclusion of complex aortic aneurysm with chimney endovascular aortic repair is applicable in a minority of patients treated with fenestrated endografts

Kliewer M, Pelanek-Völk E, Plimon M, et al. Interact Cardiovasc Thorac Surg 2021;32:460–6.

Computational analysis of endovascular aortic repair proximal seal zone preservation with endoanchors: a case study in cylindrical neck anatomy

Abbott E, Dhara S, Khabaz K, et al. JVS Vasc Sci 2021;2:170–8.

Sheath-anchoring for rail guidewire technique to advance and deploy thoracic endograft in hostile anatomy

Mastrorilli D, Mezzetto L, Scorsone L, et al. Ann Vasc Surg 2021; epub ahead of press.

Initial clinical experience with a new conformable abdominal aortic endograft: aortic neck coverage and curvature analysis in challenging aortic necks

Finotello A, Schuurmann R, Di Gregorio S, et al. J Endovasc Ther 2021;28:407–14.

Use of chimney technique does not improve the outcome of endovascular aneurysm repair in patients with a hyperangulated and short proximal aortic neck

Özdemir-van Brunschot DMD, Torsello GB, Bernardini G, et al. J Endovasc Ther 2021; epub ahead of press.

Implications of abnormal ascending aorta geometry for risk prediction of acute type A aortic dissection

Della Corte A, Rubino AS, Montella AP, et al. Eur J Cardiothorac Surg 2021;60:978–86.

A novel personalized dosimetry method for endovascular aneurysm repair (EVAR) procedures

Tzanis E, Perisinakis K, Ioannou CV, et al. Eur Radiol 2021;31:6547–54.

Aortic septotomy to optimize landing zones during thoracic endovascular aortic repair for chronic type B aortic dissection

Fukuhara S, Khaja MS, Williams DM, et al. J Thorac Cardiovasc Surg 2021; epub ahead of press.

Predictors of inadequate EndoAnchors aortic wall penetration for the Endosutured therapy in hostile neck patients

Reyes Valdivia A et al. J Cardiovasc Surg (Torino). 2020 Dec;61(6):738-744.

Full-Volume Assessment of Abdominal Aortic Aneurysms by 3-D Ultrasound and Magnetic Tracking

Zielinski AH et al. Ultrasound Med Biol. 2020 Dec;46(12):3440-3447.

Physician-modified fenestrated endovascular repair of type 1A endoleaks from polymer-based low-profile endografts

Zhang L et al. Vascular. 2020 Nov 13:1708538120972242.

Comparison of Abdominal Aortic Aneurysm Sac and Neck Wall Motion with 4D Ultrasound Imaging

Derwich W et al. Eur J Vasc Endovasc Surg. 2020 Oct;60(4):539-547.

Endovascular aortic repair with the Gore Excluder Conformable endograft in severe neck angulation: Preliminary experience and technical aspects

Bonvini S et al. Vascular. 2020 Sep 1:1708538120952665.

Total Luminal Volume Predicts Risk after Endovascular Aneurysm Repair

Oliveira-Pinto J et al. Eur J Vasc Endovasc Surg. 2020 Jun;59(6):918-927.

Parallel Covered Stents Technique in the Treatment of Abdominal Aortic Diseases

Yao C et al. J Vasc Interv Radiol. 2020 May;31(5):771-777.

Cutting the Gordian Knot of Abdominal Aneurysm Hostile Neck Definitions with the Ovation Stent Graft

Georgakarakos E et al. Ann Vasc Surg. 2020 May;65:e294-e295.

Parallel Grafts to Treat Juxtarenal Aneurysms Using the Ovation Stent Graft System

Kontopodis N et al. Eur J Vasc Endovasc Surg. 2020 Sep;60(3):479.