Delayed migration due to shortening of the lower part of

AFX endograft’s main body in angled fusiform

abdominal aortic aneurysm
Katsuhiko Oda, MD, PhD, Makoto Takahashi, MD, PhD, Naoya Terao, MD, PhD, Rina Akanuma, MD,
Takahiko Hasegawa, MD, and Satoshi Kawatsu, MD, PhD, Morioka, Japan

ABSTRACT
We encountered two fusiform abdominal aortic aneurysm cases with delayed AFX endograft (Endologix Inc) migration
>4 years after placement. These cases showed shortening and slight angulation of the main body in the anteroposterior
direction. We speculate that the potential mechanism relates to the AFX portion that is easily shortened at the bifur-
cation of its stent structure. This portion might contribute to delayed migration after slight angulation of the main body.
Preoperative three-dimensional computed tomography should be performed from the anteroposterior and lateral views.
Although the AFX is useful for narrow bifurcations, one should consider the patient’s anatomy before deciding to use an
AFX endograft. (J Vasc Surg Cases Innov Tech 2023;9:101311.)
Keywords: Abdominal aortic aneurysm; Delayed migration; Endoleak; Prosthetic graft; Stent structure

The Endologix AFX (Endologix, Inc) endovascular Several studies have reported the long-term outcomes
abdominal aortic aneurysm (AAA) graft systems have a compared with other non-unibody devices.5-9 The Strata
unique unibody structure suitable for narrow aortic bifur- material of the ePTFE graft has a potential risk of type IIIb
cations in AAAs.1 However, since 2017, the Food and Drug endoleaks; thus, it was changed to Duraply in 2014.
Administration has issued several safety warnings against Although the cause of adverse outcomes with the AFX
its routine use for AAA treatment because of type III is still unknown, two studies reported that large (>60 or
endoleaks (last updated: May 17, 2023).2,3 We only use >65 mm) AAAs tended to cause sideways displacement,
the AFX for almost straight AAAs with narrow bifurca- producing type IIIa endoleaks.10,11
tions on the anteroposterior view and carefully follow- Although the postoperative state had been uneventful
up the patients. until 3 to 4 years later, we encountered two cases of
The AFX has a potential drawback of main body short- delayed migration of an AFX endograft 4 and 5 years af-
ening because of its specific structure. The stent struc- ter installation. The patients provided written informed
ture of the AFX is made of a cobalt-chromium alloy. consent for the report of their case details and imaging
The AFX prosthetic graft is composed of expanded poly- studies and archiving of their medical records. Further-
tetrafluoroethylene (ePTFE). Fixation of the outer pros- more, we hypothesized that the specific structure of
thetic graft to the inner stent structure is limited at the the AFX could be a potential cause of delayed migration.
proximal and distal ends by sutures; thus, most ePTFE
grafts of the AFX main body can easily expand outward.
CASE REPORT
This expansion can cause “active proximal sealing.”1,4
Patient 1. A 68-year-old female patient underwent endovas-
However, it can also generate a force that shortens the
cular aortic repair (EVAR) using the main body of an AFX endograft
main body of the AFX. To counteract this possible draw-
with Duraply without an aortic cuff for a fusiform AAA with a narrow
back, the length of the stent structure should be main-
aortic bifurcation in 2017. The postoperative course was uneventful
tained by complete fixation of all stents.
for 4 years, and the minimum AAA diameter gradually reduced.
However, we noted a gradual downward migration of the main
From the Department of Cardiovascular Surgery, Iwate Prefectural Central body of the AFX. Dislodging of the AFX main body from the neck
Hospital. was detected at the 5-year follow-up visit in 2022. The main body’s
Presented at the session of the president’s requested theme at the Fifty-first length had decreased from 10.96 cm to 9.64 cm (
1.32 cm; Fig 1),
Annual Meeting of the Japanese Society for Vascular Surgery, Shinjuku-Ku, causing a type Ia endoleak and recurrent AAA enlargement. Thus,
Tokyo, Japan, May 31 to June 2, 2023.
we performed urgent repeat EVAR using the Endurant aorto-uni-
Additional material for this article may be found online at www.jvscit.org.
Correspondence: Katsuhiko Oda, MD, PhD, Department of Cardiovascular iliac stent graft (Medtronic) and femorofemoral bypass (Fig 2). Her
Surgery, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka 020-0066, postoperative course was uneventful.
Japan (e-mail: oda2015@gmail.com).
The editors and reviewers of this article have no relevant financial relationships to Patient 2. An 84-year-old male patient underwent EVAR us-
disclose per the Journal policy that requires reviewers to decline review of any ing the main body of an AFX 2 with an aortic cuff for a fusiform
manuscript for which they may have a conflict of interest. AAA with a narrow aortic bifurcation in 2018. The postoperative
2468-4287
course was uneventful, and follow-up computed tomography
Ó 2023 The Author(s). Published by Elsevier Inc. on behalf of Society for Vascular
Surgery. This is an open access article under the CC BY-NC-ND license (http://
showed no endoleaks for >3 years. However, slipping of the
creativecommons.org/licenses/by-nc-nd/4.0/). main body of the AFX from the aortic cuff was detected at the 4-
https://doi.org/10.1016/j.jvscit.2023.101311 year follow-up visit in 2022. The main body length of the AFX

1
2 Oda et al Journal of Vascular Surgery Cases, Innovations and Techniques
December 2023

Fig 1. Three-dimensional computed tomography lateral view of patient 1. A, Postoperative day 3. B, Five years
later.

Fig 2. Postoperative three-dimensional computed tomography image of patient 1 after repeat endovascular
aortic repair (EVAR). AP, Anteroposterior.

had decreased from 7.5 cm to 6.2 cm (
1.3 cm), and the main performed urgent repeat EVAR, similar to that for patient 1. His
body had moved slightly forward. The aortic cuff remained in postoperative course was uneventful.
the same position (Fig 3). The length between the cuff’s proximal
edge and bifurcation had increased (þ2.42 cm). The overlap DISCUSSION
between the main body and the cuff was extremely reduced Between 2010 and 2022, we encountered 52 cases of
(
3 cm), and a type IIIa endoleak was detected. Thus, we AFX used for AAAs at our institute. The AAA morphologies
Journal of Vascular Surgery Cases, Innovations and Techniques Oda et al 3
Volume 9, Number 4

Fig 3. Three-dimensional computed tomography lateral view of patient 2. A, Postoperative day 3. B, Four years
later.

Fig 4. Potential mechanisms of delayed AFX migration in abdominal aortic aneurysms (AAAs). A, A case
without angulation. B, Patient 1 (without an aortic cuff). C, Patient 2 (with an aortic cuff). Black dots indicate
stent structures; white line, expanded polytetrafluoroethylene (ePTFE) graft; and red arrows, blood flow
direction.
4 Oda et al Journal of Vascular Surgery Cases, Innovations and Techniques
December 2023

were fusiform for 36, saccular-shaped for 12, and local both the anteroposterior and the lateral views should be
dissection or pseudoaneurysm for 4. The delayed migra- reviewed during preoperative EVAR planning. If a slight
tion rate was 5.6% (2 of 36) for the fusiform AAAs and angulation of the main body of the AFX is predicted preop-
0% (0 of 16) for the saccular-shaped AAAs, local dissec- eratively, the use of the AFX should be avoided.
tions, and pseudoaneurysms. Furthermore, we investi-
gated the morphologic differences between the cases of CONCLUSIONS
delayed migration and no migration of fusiform AAAs. We encountered two cases of delayed AFX migration
We focused on the shape of the main body of the AFX due to main body shortening. The flexible lower part of
after its placement. In the cases without migration, the the stent’s main body and the force of the blood flow
main body was almost straight. In contrast, in the cases that hits the lower anterior wall could have played
with delayed migration, it was angulated by >30 in pivotal roles in the delayed migration. If a slight angula-
the anteroposterior direction. The neck angulation was tion of the main body of the AFX is predicted preopera-
not associated with delayed migration. Three cases had tively in the anteroposterior direction, AFX use should
neck angulation >30 . However, these cases showed no be avoided. Although the AFX endograft is useful for nar-
migration, and the main body was almost straight. We row bifurcations, its use should be carefully considered
hypothesized that the slight angulation of the main according to the patient’s anatomy.
body in the anteroposterior direction in the fusiform
AAAs is important for delayed migration. A large fusiform We thank Editage (www.editage.com) for the English
AAA (>60 or >65 mm) that provides space for migration language editing.
could also play a vital role, as previously reported.10,11 DISCLOSURES
Saccular or locally dissected AAAs with no movement None.
space showed no migration in our series and might be
more suitable for AFX use. REFERENCES
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