title: Management of late main-body aortic endograft component uncoupling and type IIIa endoleak encountered with the Endologix Powerlink and AFX platforms.
abstract: OBJECTIVE
  Junctional component separation producing type IIIa endoleak after endovascular abdominal aortic aneurysm repair (EVAR) is an uncommon but serious complication requiring unanticipated reinterventions. This retrospective study analyzed main-body EVAR component uncoupling and type IIIa endoleaks encountered with Powerlink and AFX (Endologix Inc, Irvine, Calif) endografts during an 8-year period.
  
  
  METHODS
  Type IIIa endoleaks were identified from a database of secondary interventions and clinical surveillance. Operative reports, medical records, and computed tomography studies were reviewed. Clinical and imaging characteristics were analyzed over time, and differences were compared at appropriate follow-up intervals.
  
  
  RESULTS
  Since 2006, 701 patients underwent primary EVAR using Endologix Powerlink (352 patients, 2006-2011) or AFX (349 patients, 2011-2014) endografts. Endoleaks required 32 secondary interventions (4.6%), including type Ia in 4 patients (1 proximal extension and 3 explants); type Ib in 8 patients (all distal extensions for enlarging iliac aneurysms); type II in 1 patient (explant); type IIIa in 17 patients (2.4%), who were the subject of this report; and type IIIb in 2 patients (both EVAR relining). The 17 patients with type IIIa endoleak were an average age of 71 years, and 14 (82%) were men. The mean preoperative abdominal aortic aneurysm (AAA) diameter was 70 ± 18 mm. The repair was elective in 16 patients and an emergency in one. Ten cases were performed with Powerlink and seven with AFX. Analysis of serial computed tomography scans found significant changes in AAA diameter; renal-to-bifurcation straight-line, centerline, and greater curvature lengths; EVAR angulation; and loss of EVAR component overlap. The average time from EVAR to reintervention was 32 months. Three patients returned with a ruptured AAA and three with AAA thrombosis, and three of these patients (18%) died ≤30 days of the emergency reintervention. Secondary procedures included EVAR relining with additional bridging components in 14 patients (82%), explant in 2, and axillobifemoral bypass in 1. No new cases of endograft uncoupling have been identified in patients treated with AFX since December 2012 after adoption of revised instructions for use.
  
  
  CONCLUSIONS
  Although a small number of secondary interventions were needed after EVAR with the Endologix Powerlink or AFX endografts, most were undertaken for late main-body component uncoupling and type IIIa endoleak, which can occur after sideways displacement of the endograft in large and angulated AAAs. Patients treated before 2013 under the old instructions for use should be evaluated for signs of impending component separation and monitored annually, noting that expected indicators of endograft failure, such as increasing AAA diameter and endoleak, may be absent.
authors.affiliation: Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn. Electronic address: afshin.skibba@gmail.com.
authors.forename: Afshin A
authors.initials: AA
authors.lastname: Skibba
authors.affiliation: Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn.
authors.forename: James R
authors.initials: JR
authors.lastname: Evans
authors.affiliation: Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn.
authors.forename: David Tyler
authors.initials: DT
authors.lastname: Greenfield
authors.affiliation: Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn.
authors.forename: Heesuk Richard
authors.initials: HR
authors.lastname: Yoon
authors.affiliation: Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn.
authors.forename: Tony
authors.initials: T
authors.lastname: Katras
authors.affiliation: Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Ouriel
authors.affiliation: Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Rush
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D015897:Comorbidity; D004630:Emergencies; D057867:Endoleak / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D012422:Rupture, Spontaneous; D014057:Tomography, X-Ray Computed