The angulated aneurysm neck is an essential parameter that directly influences accurate graft deployment at the proximal landing zone. However, if it is also short, thrombosed or calcified, an angulated neck may influence whether there is sufficient sealing of the aneurysm sac and stent graft fixation during the long-term follow-up. The degree of aortic arch angulation is also an important anatomical feature that has to be considered when selecting patients for graft surgery [13, 14, 23, 46]. In the thoracic aortic position, severe neck angulation is a challenge independent of the other neck characteristics. In an angulated aortic arch, it is difficult to insert the delivery system and special modifications and tricks have to be used in order to facilitate the insertion. The use of an extra stiff guidewire, which builds a loop inside the ascending aorta, is the standard technique for placing the delivery system into a mild or moderately elongated aortic arch. The through-and-through brachial wire technique is more efficient for inserting the sheath into an extremely angulated aortic arch. Flexible sheaths and graft are made and help to achieve successful graft deployment in this position. Pre-curved sheaths are very useful for patients with severe aortic arch angulation [23, 40, 46]. Regarding AAAs, the incidence and prevalence of aortic neck angulation depend on its definition. According to Carpenter  angulations are classified in three categories: (1) less then 30°, (2) 30-60° and (3) greater than 60°. Mild angulations (<30°) are frequent in AAA patients, while
moderate angulations (30-60°) are described in 25% of patients with AAA [13, 54]. Severe angulations (>60°) at the aortic neck are present in less than 10% of AAA cases (Fig. 5.4.2). In these cases, Carpenter recommends open repair surgery as long as the patients are medically fit. In any case EVAR for such patients demands a long neck length and endograft with suprarenal fixation and high radial force .
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