Durable Limb Patency After EVAR Using Parallel Excluder Limbs for Narrow Distal Aortas: A Retrospective Cohort Study

BACKGROUND: A narrow distal aorta is a recognized risk factor for limb patency loss and graft-related complications following endovascular aneurysm repair (EVAR). This study aimed to evaluate limb occlusion-free survival and patency outcomes following EVAR using bilateral Gore Excluder iliac limbs in patients with distal aortic diameters <18 mm. METHODS: In this single-center, retrospective cohort study, 87 patients with infrarenal abdominal aortic aneurysms and distal aortic diameters <18 mm measured immediately proximal to the aortic bifurcation, who underwent EVAR between April 2013 and January 2024, were included. Bilateral Gore Excluder limbs were deployed within the narrow distal aorta in all cases. The primary endpoint was limb occlusion-free survival. Secondary endpoints included primary patency, limb-related reintervention, aortic-related mortality, changes in cross-sectional area, and the ankle-brachial index (ABI) over time. RESULTS: The median follow-up duration was 2.6 years (range: 0.01-10.1 years). No limb occlusions or aortic-related deaths were observed during follow-up in this cohort. Limb-related reinterventions were not required. Cross-sectional area increased at midterm follow-up. ABI values remained stable between limbs during early and midterm follow-up. CONCLUSION: EVAR using bilateral Gore Excluder iliac limbs in distal aortas <18 mm was associated with favorable midterm limb patency, with no limb occlusions or aortic-related mortality observed during midterm follow-up in this cohort.Clinical ImpactEndovascular repair using parallel Gore Excluder limbs may represent a feasible treatment option for patients with narrow distal aortas, a group traditionally considered at high risk for standard EVAR. This study reports midterm clinical outcomes in patients treated with this strategy, with no limb occlusions or aortic-related deaths observed during follow-up. By confirming durable patency and procedural safety in anatomically complex cases, these findings provide clinical insight into the use of this strategy in patients with narrow distal aortas in contemporary clinical practice.