Overcoming hostile neck anatomy in endovascular abdominal aortic aneurysm repair using the reverse slider technique – a case report

Background: Around 40-60% of abdominal aorta aneurysm (AAA) patients are deemed to be outside the instructions for use (IFU) for endovascular aneurysm repair (EVAR) because of hostile anatomy. Short and angulated necks pose a serious risk of type IA endoleak due to the difficulty in achieving proper proximal fixation and endograft seal. Report: A 72-year-old male with a history of dyslipidemia and smoking was admitted to the vascular ward with a diagnosis of an AAA with 85-mm in diameter. The patient had recently undergone a Hartmann procedure for transmural ischemic colitis. Despite suboptimal anatomy for EVAR, including a short proximal neck (13 mm) and severe infrarenal angulation (90°), endovascular repair with the Endurant II stent graft was performed, using the reverse slider technique. The procedure was technically successful, with angiography confirming proper graft fixation and aneurysm exclusion. Follow-up Computed Tomography Angiography at one month demonstrated correct positioning of the endograft with no evidence of endoleak. Conclusion: The reverse slider technique allows proximal sealing in short and angulated neck aneurysms. It involves the repeated rotation of the external slider in the reverse direction, accompanied by gradual deployment of the suprarenal stent, allowing the proximal edge of the endograft to gradually expand, progressively approaching the contralateral side of the aortic wall.