A 6.1 cm AAA with a Short Angulated Neck, Calcified Iliac Access, and Recent Coronary Stenting

The anatomy makes standard EVAR high risk: an 8 mm neck with 75° angulation and mural thrombus predisposes to inadequate seal, type Ia endoleak, and migration. The 5 mm calcified iliac arteries make device delivery hazardous and may require adjuncts or a conduit. Open repair is also high risk because of the hostile abdomen, poor pulmonary reserve, and renal impairment, but it avoids contrast and provides a durable repair. The recent drug-eluting stent is a major timing issue. Elective surgery within 4 months of a DES is associated with stent thrombosis, so if repair can safely wait, I would defer until at least 6 months and preferably 12 months after stenting. However, a 6.1 cm AAA has a meaningful rupture risk, so deferral must be balanced against that risk. I would involve cardiology in a shared decision: if the aneurysm is rapidly expanding or symptomatic, repair may need to proceed earlier with continued aspirin and a planned antiplatelet bridge. Fenestrated repair is attractive for the neck but requires larger access and more contrast, which is problematic with an eGFR of 32 and 5 mm iliacs. This is a case for a multidisciplinary aortic team, not a single-modality decision.

For the neck, I would consider endoanchors to improve fixation and seal, and I would avoid oversizing beyond the manufacturer's recommendation because mural thrombus and angulation increase the risk of infolding and type Ia endoleak. A fenestrated device could treat a short neck, but it requires a custom manufacturing delay and larger delivery systems, which are difficult with 5 mm calcified iliacs. A chimney or snorkel technique can preserve renal arteries but creates gutter leaks and is not ideal in an elective patient with a short neck. For access, intravascular lithotripsy, cutting balloons, or iliac conduits may allow delivery, but each adds risk. The limits are important: if a durable seal cannot be achieved, standard EVAR should be abandoned rather than accepted with a high likelihood of late failure. If the iliac access cannot be made safe, open repair or a hybrid approach may be preferable. The patient should be counseled that EVAR with adjuncts is not equivalent to a straightforward EVAR and may require reintervention.

For open repair, I would stop ticagrelor about 5 days before surgery and continue aspirin, because ticagrelor carries a higher bleeding risk and cannot be fully reversed. I would involve cardiology and consider bridging only if the stent is very recent or the coronary anatomy is high risk, but routine bridging increases bleeding. For EVAR, the procedure is less invasive and can often be performed on dual antiplatelet therapy, but access-site bleeding and groin hematoma are still concerns. The evidence favors delaying elective noncardiac surgery for at least 6 months after DES implantation when possible, because stent thrombosis risk is highest in the first months. After 6 months, aspirin alone is often sufficient, but this patient's cardiologist wants 12 months. I would document a shared decision that balances aneurysm rupture risk against stent thrombosis. If repair must proceed before 6 months, I would prefer an approach that allows continuation of dual antiplatelet therapy, which favors EVAR if anatomically feasible, and I would have platelet transfusion available for open repair.