Which statement best describes common contraindications or limitations to EVAR and when alternatives might be used?

• A. Inadequate proximal or distal seal zones, hostile neck anatomy, extreme tortuosity, and poor access.
• B. EVAR is always feasible regardless of anatomy.
• C. Good neck anatomy guarantees EVAR success in all cases.
• D. Extreme tortuosity is not a limitation to EVAR.

Answer: (D)

Endovascular aneurysm repair works best when there is a solid landing zone for the graft and a relatively straightforward path for delivery. When the proximal or distal sealing zones are inadequate, when the neck anatomy is hostile (short, highly angulated, with thrombus or calcification), when there is extreme tortuosity, or when the access vessels are poor, the graft may not seal or track properly. In these situations, the procedure carries higher risks of endoleaks, graft mispositioning, or failure, so alternatives are considered—such as open surgical repair or more complex endovascular solutions like fenestrated/branched devices or conduit extensions. That’s why statements that EVAR is always feasible regardless of anatomy or that good neck anatomy guarantees success don’t fit, and extreme tortuosity is indeed a real limitation to EVAR.