Do Not Mix It up! Long-Term Outcomes of Different Proximal Aortic Cuffs with the AFX Endograft

The AFX unibody endograft offers advantages in treating abdominal aortic aneurysms (AAAs) with narrow aortic bifurcations due to its unique design, where the flow divider sits at the native aortic bifurcation. However, its limited length options may limit complete proximal neck utilization. As per device instruction for use, the implant should be completed with an aortic cuff. This study aims to evaluate the long-term outcomes of patients treated with an all-Endologix implant versus a combination of Endologix and Medtronic devices.

This retrospective, single-center study included 134 consecutive AAA patients who underwent endovascular aneurysm repair (EVAR) using the AFX unibody endograft paired with suprarenal aortic cuffs from Endologix (n = 86) or Medtronic (n = 48) between November 2011 and November 2022. Patients were divided into 2 groups based on the type of aortic cuff used. The primary outcome was the occurrence of type 3A endoleaks at the longest available follow-up. Secondary outcomes included any endoleak, reintervention rates, all-cause mortality, and aneurysm-related death.

The median follow-up was 41 months, and type 3A endoleaks occurred after a mean 34.8 months in 6 patients (4.5%), which is significantly more frequent in the mixed-device group (12.8%) (P < 0.001). Type 3A endoleak occurred regardless of overlap and developed over time. Endoleaks of any type were reported in 17 patients. Reinterventions were needed in 12 patients. The use of an Endurant cuff was associated with a significantly increased risk of type 3A endoleaks (hazard ratio [HR] 16.5; 95% [CI] 1.9-143; P = 0.011) and reinterventions (HR 9.67; 95% CI 1.9-49.6; P = 0.006).

Combining endografts from different manufacturers, especially those with differing materials and sealing mechanisms, may compromise the long-term integrity of certain EVAR repairs. Clinicians should exercise caution when considering mixed-device configurations and ensure rigorous follow-up for patients with such implants.