Clinical benefits and risks of the wall-push technique in endovascular repair of abdominal aortic aneurysm with severely angulated neck: a case report

Background: Endovascular aneurysm repair (EVAR) has become the preferred treatment for infrarenal abdominal aortic aneurysms (AAA), offering reduced morbidity and faster recovery compared with open surgery. However, patients with complex neck anatomy pose significant technical challenges, and current treatment approaches carry inherent risks. Learning from and summarizing experiences from these complex cases is crucial for advancing EVAR techniques. Case summary: An 80-year-old female with a 10-year history of conservatively managed infrarenal AAA complained of intermittent abdominal pain for 1 week. Computed tomography angiogram (CTA) demonstrated a tortuous infrarenal AAA with a tapered neck. Aneurysmal dilatation and severe calcification of bilateral iliac arteries and tortuous aortoiliac access were also shown. EVAR was performed successfully using Gore Excluder C3 stent-grafts (W.L. Gore & Associates, Flagstaff, AZ, USA). During deployment, inadvertent forward displacement of the guidewire caused an iatrogenic abdominal aortic dissection above the left renal artery. The false lumen was immediately coil-embolized with five interlock coils, successfully excluding the dissection flap and restoring antegrade flow. The procedure was completed uneventfully, with the stent-graft well positioned, patent, and free of endoleak. Discussion: The case highlights both the utility and risks of advanced EVAR techniques in complex anatomy. The wall-push technique, while useful for severe neck angulation, requires meticulous guidewire control and carries risk of vessel injury. Key preventive measures include continuous fluoroscopic monitoring, team communication, consideration of safety wires, and careful preoperative assessment. The learning curve for advanced techniques is steep, emphasizing the need for proper training, experience, and comprehensive preoperative planning using three-dimensional CTA reconstruction.