Which statement most accurately summarizes 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 suitable for any aneurysm regardless of neck anatomy.
• C. Only age determines EVAR feasibility.
• D. Renal function alone determines EVAR suitability.

Answer: (A)

Endovascular aneurysm repair hinges on having secure landing zones and a clear path to deliver the graft. If the proximal seal zone is inadequate (too short, irregular, or heavily calcified), or the distal seal zone in the iliac vessels is poor, the graft cannot seal effectively, raising risks of endoleak and graft migration. Hostile neck anatomy—short, sharply angled, conical, or heavily calcified—compromises fixation and sealing. Extreme tortuosity of the vessels makes advancing and correctly positioning the device difficult and increases the chance of graft kink or maldeployment. Poor access due to small or diseased femoral/iliac arteries can prevent device delivery altogether, necessitating alternative strategies. When these anatomical or access issues are present, alternatives such as open surgical repair or specialized endografts (fenestrated/branched) or hybrid approaches are considered. Age or renal function alone do not determine EVAR feasibility; they influence risk and management but are not the primary technical constraints.