Coupling Failure after 4 Years of EVAR with AFX2 Endografts Used in Combination with Aortic Cuffs

Abstract

The Endologix AFX is a bifurcated unibody endovascular aortic repair （EVAR） system used for the treatment of abdominal aortic aneurysms （AAA）. It consists of an inner metal endoskeleton with multiple metal struts covered by a polytetrafluoroethylene graft fabric, which is suitable for treating AAA with narrowed abdominal aortic bifurcations. However, the risk of type 3 endoleak （T3EL） has been alerted and it is recommended that a sufficient overlap length be considered when using a cuff device on the central side. We present the case of an 81-year-old man with a 45 mm AAA who underwent EVAR with an AFX2 main body device and AFX proximal cuff extension device, adhering to the recommended overlap length. However, postoperative aneurysm enlargement occurred gradually, and complete uncoupling of the main body and cuff was observed 4 years later. A retrospective review of 4 years of computed tomography （CT） scans revealed potential caudal migration of the main body device and cranial migration of the cuff device, potentially resulting in a type 3a endoleak （T3aEL）. An additional device was deployed to bridge both components, and the patient was discharged without complications. In cases where an AFX2 main body device and a cuff device are used on the central side, even with adequate overlap, careful follow-up is necessary because of the potential for sideways displacement or craniocaudal migration. The observation of device displacement using 3D reconstruction CT imaging is particularly useful.