Standard endovascular treatment of abdominal aortic aneurysms in patients with very short proximal necks using the Endurant stent graft

The Effect of One Year Aneurysm Sac Dynamics on Five Year Mortality and Continued Aneurysm Sac Evolution

OBJECTIVE

One year aneurysm sac dynamics after endovascular abdominal aortic aneurysm repair (EVAR) were independently associated with a greater all cause mortality risk in prior registry studies but were limited in completeness and granularity. This retrospective analysis aimed to study the impact of sac dynamics on survival within the Endurant Stent Graft Global Registry (ENGAGE) with five year follow up.

METHODS

A total of 1 263 subjects were enrolled in the ENGAGE Registry between March 2009 and April 2011. One year aneurysm sac changes were calculated between the one month post-operative imaging scans and the scan closest to the time of one year follow up. Sac regression was defined as a sac decrease of ≥ 5 mm and sac expansion as aneurysm sac growth ≥ 5 mm. The primary outcome was the five year all cause mortality rate. Kaplan-Meier estimates for freedom from all cause death were calculated. Multivariable Cox regression was used to determine the association between sac dynamics and all cause death.

RESULTS

At one year, 441 of the 949 study participants with appropriate imaging (46%) had abdominal aortic aneurysm sac regression, 462 (49%) remained stable, and 46 (4.8%) had sac expansion. For patients with sac regression, the five year all cause mortality rate was 20%, compared with 28% for stable sac (p = .007) and 37% for the sac expansion (p = .010) cohorts. After adjustment, the sac expansion and stable sac cohorts were associated with a greater all cause mortality rate (expansion: hazard ratio [HR] 1.8; 95% CI 1.1 - 3.2; p = .032; stable: HR 1.4; 95% CI 1.1 - 1.9; p = .019).

CONCLUSION

In the ENGAGE Global Registry, the one year rate of sac regression was 46%, and one year sac regression was observed to be associated with greater five year survival, corroborating prior findings using data from vascular registries. Sac regression could become the new standard for success after EVAR.

Long-term outcomes of the Endurant endograft in patients undergoing endovascular abdominal aortic aneurysm repair

OBJECTIVE/BACKGROUND

To investigate the long-term outcomes after endovascular aneurysm repair (EVAR) in a real-world setting using the Endurant endograft (EG).

METHODS

184 EVAR candidates treated with the Endurant family EGs in a single vascular center were prospectively enrolled from January 2009 to December 2016. Kaplan-Meir estimates of long-term standardized primary and secondary outcome measures were performed. Per protocol, subgroup comparison analysis was performed in three groups: patients treated within instructions for use (in-IFU) vs patients treated outside IFU (outside-IFU), EVAR in patients receiving the Endurant proximal diameter 32 or 36 mm EG vs those receiving the <32 mm diameter EG and EVAR with various Endurant EG versions.

RESULTS

The mean follow-up was 75.09 ± 37.9 months (range: 4.1-172 months). The median age of the patients was 72.96 ± 7.03 years (range: 55-88 years). A total of 177 patients were male (96.2%). Compliance with IFU was followed in 107 patients (58.2%). Overall survival was 69.5% and 48% at 5 and 8 years, respectively. Of the 102 all-cause deaths, 7 (6.9%) were aneurysm related. Six of these postimplant deaths occurred in patients presented with aneurysm rupture from type Ia or/and type Ib endoleak. At 5, 8, and 10 years of observation, freedom from aneurysm rupture, open surgical conversion, type I/III endoleak, any type of endoleak, aneurysm-related secondary intervention probabilities, and neck-related events were as follows: 98.1%, 95%, and 89.4%; 95.1%, 91.2%, and 85.7%; 93.6%, 87.3%, and 83.9%; 83.4%, 74%, and 70.9%; 89.8%, 76.7%, and 72%; and 96.3%, 90%, and 87.6%, respectively. Corresponding clinical success was 90%, 77.4%, and 68.4%, respectively. Patients treated outside-IFU had significantly higher risk of aneurysm rupture, open surgical conversion probability, occurrence of type I/III endoleak, and chance of reinterventions and lower clinical success probabilities compared with the in-IFU counterparts at 5 and 8 years. This statistical difference remained when type Ia endoleak or endoleak of any type was considered independently. In addition, it was stronger in patients having extreme anatomic boundaries (>1 hostile anatomic condition), when aneurysm-related death, aneurysm rupture, and clinical success at 5 years were considered. Overall proximal migration and limb occlusion were recorded in 1.1% and 4.9% of the patients, respectively. Overall reintervention rate was 17.4%. An increase in aneurysm sac diameter was observed in 12.5% of patients and was not related to IFU status. The Endurant version or the proximal EG diameter had no significant association with the chance of any complication or adverse event.

CONCLUSIONS

The data confirmed the durability of the Endurant EG, achieving promising long-term outcomes in a real-world setting. However, its positive performance must be interpreted with caution in patients treated off-label especially those with extreme anatomic boundaries. In this cohort, some of EVAR advantages might be lost in the late future. Further similar studies are warranted.

A radiomics model for predicting the outcome of endovascular abdominal aortic aneurysm repair based on machine learning

OBJECTIVE

This study aimed to develop a radiomics model to predict the outcome of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), based on machine learning (ML) algorithms.

METHODS

We retrospectively reviewed 711 patients with infra-renal AAA who underwent elective EVAR procedures between January 2016 and December 2019 at our single center. The radiomics features of AAA were extracted using Pyradiomics. Pearson correlation analysis, analysis of variance (ANOVA), least absolute shrinkage, and selection operator (LASSO) regression were applied to determine the predictors for EVAR-related severe adverse events (SAEs). Eighty percent of patients were classified as the training set and the remaining 20 percent of patients were classified as the test set. The selected features were used to build a radiomics model in training set using different ML algorithms. The performance of each model was assessed using the area under the curve (AUC) from the receiver operating characteristic (ROC) curve in the test set.

RESULTS

A total of 493 patients were enrolled in this study, the mean follow-up time was 32 months. During the follow-up, 156 (31.6%) patients experienced EVAR-related SAEs. A total of 1223 radiomics features were extracted from each patient, of which 30 radiomics features were finally identified. The quantitative performance assessment and the ROC curves indicated that the logistics regression (LR) model had better predictive value than others, with accuracy, 0.86; AUC, 0.93; and F1 score, 0.91. The Rad-score waterfall plot showed that the overall amount of error was small both in the training set and in the test set. Calibration curve showed that the calibration degree of the training set and the test set were good (p > 0.05). Decision curve analysis (threshold 0.32) demonstrated that the model had good clinical applicability.

CONCLUSION

Our radiomics model could be used as an efficient and adjunctive tool to predict the outcome after EVAR.

Five-year outcomes of the Bi- versus Trimodular EndurantTM stent-graft in 100 patients with infrarenal abdominal aortic repair

BACKGROUND

Recent studies on the Endurant™ endografts mainly compared outcomes of the bimodular stent-graft to other manufacturer's endografts or reported results for cases outside manufacturer's instructions for use (IFU), while data on the experience of standard endovascular aortic repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) inside manufacturer's IFU comparing the bi- with the trimodular device is limited.

METHODS

Inclusion criteria were: 1) infrarenal aneurysms (>50 mm diameter) treated by Endurant^TM II (END II) or Endurant^TM IIs (END IIs) stent-graft inside manufacturer's IFU; 2) available CTA with 1 mm reconstruction of the entire aorta prior to intervention. Endpoints comparing the devices included technical success, 30-day mortality, rate of complications (bleeding with conversion to open repair, stent-graft stenosis/occlusion, acute distal embolism, infection or postprocedural necessity of dialysis), endoleaks and reinterventions (5-year follow-up). Aneurysm sac diameters were compared between baseline preinterventional CTA and last post-interventional CTA.

RESULTS

One hundred patients (90% male, mean age 74 years) treated with END II (N.=66) or END IIs (N.=34) were included. Technical success was 99%. One procedure-related active bleeding occurred ending up in surgical conversion (END II N.=1). 30d mortality was 0%. No initial type I/III endoleaks were present. Re-interventions were required in 19/100 (19%) of patients (END II N.=10; END IIs N.=9, P=0.17). The outcome of EVAR including technical success, 30d mortality, rate of complications, endoleaks and re-interventions showed no significant differences comparing END II/IIs.

CONCLUSIONS

Five-year outcomes of EVAR show consistently safe and effective results for either END II or IIs device.

Fully automatic segmentation of abdominal aortic thrombus in pre-operative CTA images using deep convolutional neural networks

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) is currently established as the first-line treatment for anatomically suitable abdominal aortic aneurysm (AAA).

OBJECTIVE

To establish a deep convolutional neural networks (DCNN) model for fully automatic segmentation intraluminal thrombosis (ILT) of abdominal aortic aneurysm (AAA) in pre-operative computed tomography angiography (CTA) images.

METHODS

We retrospectively reviewed 340 patients of AAA with ILT at our single center. The software ITKSNAP was used to draw AAA and ILT region of interests (ROIs), respectively. Image preprocessing and DCNN model build using MATLAB. Randomly divided, 80% of patients was classified as training set, 20% of patients was classified as test set. Accuracy, intersection over union (IOU), Boundary F1 (BF) Score were used to evaluate the predictive effect of the model.

RESULTS

By training in 34760-35652 CTA images (n= 204) and validation in 6968-7860 CTA images (n=68), the DCNN model achieved encouraging predictive performance in test set (n= 68, 6898 slices): Global accuracy 0.9988 ± 5.7735E-05, mean accuracy 0.9546 ± 0.0054, ILT IOU 0.8650 ± 0.0033, aortic lumen IOU 0.8595 ± 0.0085, ILT weighted IOU 0.9976 ± 0.0001, mean IOU 0.9078 ± 0.0029, mean BF Score 0.9829 ± 0.0011. Our DCNN model achieved a mean IOU of more than 90.78% for segmentation of ILT and aortic lumen. It provides a mean relative volume difference between automatic segmentation and ground truth (P> 0.05).

CONCLUSION

An end-to-end DCNN model could be used as an efficient and adjunctive tool for fully automatic segmentation of abdominal aortic thrombus in pre-operative CTA image.

Endovascular aortic repair with the Gore Excluder Conformable endograft in severe neck angulation: Preliminary experience and technical aspects

OBJECTIVES

Endovascular procedures are now the standard of care for endovascular aortic aneurysm repair but treatment of hostile proximal neck anatomy is still challenging. New endografts were brought to the market specifically designed to accommodate severe neck angulation. Authors describe a preliminary experience and early results using the Gore Excluder Conformable endograft (W. L. Gore & Associates, Flagstaff, Ariz) and its active control system in severe neck angulation with a standardized technical approach to achieve precise deployment in this hostile anatomy.

METHODS

From June 2019 to May 2020, five patients with abdominal aortic aneurysm and severe neck angulation (≥70°) were treated with the Gore Excluder Conformable endograft at two different centers. Deployment of this endograft in this kind of anatomy should be aggressive starting over the level of renal arteries due to risk of distal migration downward on the external curvature and difficulty in upward repositioning. Authors suggested a standard technique with a routine through-and-through axillary-femoral approach, using a floppy guidewire together with preventive cannulation of the lower renal artery if a short neck (<15 mm) is associated.

RESULTS

Endovascular aortic procedures were successfully completed in all patients. Final deployment of the stent graft using our standardized technical approach was extremely precise in all cases even if redeployment of the graft was necessary in all cases. No other secondary procedures were needed. At 30 days, no type IA endoleak was recorded and no aneurysm-related secondary procedures were performed. Median follow-up for this group of patients was 5.2 months (range 1-11). Early results revealed no type IA endoleak and no migration at Ct angiogram. No aneurysm-related secondary procedures were required.

CONCLUSION

Routine use of through-and-through axillary-femoral guidewire associated with selective pre-cannulation of the lower renal artery allows a precise deployment of the Gore Excluder Conformable endograft in difficult anatomies possibly affecting early outcomes.

Endovascular Aortic Repair with the "Step-by-Step" Deployment of the Endurant Stent-Graft System in Severe Neck Angulation: Technique and Review of the Literature

OBJECTIVES

To describe a new technique based on a different deployment of the Endurant Stent-Graft System (Medtronic Cardiovascular, Santa Rosa, CA) during endovascular aortic aneurysm repair to guarantee a more precise deployment in presence of severe neck angulation (SNA).

TECHNIQUE

The "step-by-step" deployment technique consists of an alternate partial release of the main body and of the free-flow suprarenal stents to approximate the radiopaque markers of the graft fabric to the aortic wall, obtaining a more precise delivery, reducing the possibility of downward dislodgments along the external curve of the infrarenal angle and asymmetrical deployments in presence of SNA.

CONCLUSIONS

The "step-by-step" technique is a simple, safe, and effective graft-deployment method, which allows a very precise release in SNA and possibly achieves better results in the long-term period in such difficult anatomies.

Female sex is associated with comparable 5-year outcomes after contemporary endovascular aneurysm repair despite more challenging anatomy

BACKGROUND

Women with abdominal aortic aneurysms less often meet anatomic criteria for endovascular repair and experience worse perioperative and long-term survival.

METHODS

We compared long-term survival, aneurysm-related mortality, and rates of endoleaks and reinterventions between male and female patients in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) using 2:1 propensity score matching.

RESULTS

There were 1130 male patients and 133 female patients, yielding 399 patients after matching (266 male patients, 133 female patients). Female patients were older, with smaller aneurysms, smaller iliac arteries, and shorter, more angulated necks, and they were more often treated outside the device instructions for use (all P < .001). Through 5 years, female patients experienced overall mortality comparable to that of well-matched male patients (34% vs 38%, respectively; hazard ratio, 0.89 [0.61-1.29]; P = .54) and lower aneurysm-related mortality (0% vs 3%; P = .047). Female patients experienced higher rates of any postoperative type IA endoleak through 5 years (10% vs 1%; P < .001) but comparable rates of secondary endovascular procedures (14% vs 16%; P = .40). Female sex was independently associated with significantly higher risk of long-term type IA endoleaks (hazard ratio, 4.8 [1.2-20.8]; P = .04), even after accounting for anatomic factors. No female patient experienced aneurysm rupture during follow-up, and only one female patient underwent conversion to open repair.

CONCLUSIONS

Despite more challenging anatomy, female patients in the ENGAGE registry had long-term outcomes comparable to those of male patients. However, female patients experienced higher rates of type IA endoleaks. Although standard endovascular aneurysm repair remains a viable solution for most women, whether high-risk patients may be better served with open surgery, custom-made devices, EndoAnchors (Aptus Endosystems, Sunnyvale, Calif), or chimneys is worthy of further study.

Hostility of proximal aortic neck anatomy in relation to abdominal aortic aneurysm size and its impact on the outcome of endovascular repair with the new generation endografts

BACKGROUND

To assess the relation of abdominal aortic aneurysm (AAA) diameter with the proximal neck anatomy (PNA) hostility and to evaluate its impact on the endovascular aneurysm repair (EVAR) outcomes with the use of newer generation endografts.

METHODS

Retrospective analysis of single institution's recorded data from February 2009 to April 2016. Patients' characteristics, comorbidities, aortic morphology, perioperative characteristics and outcomes were analyzed. In relation to AAA diameter 2 groups were identified: group A (50-55 mm) and group B (>55 mm). Hostile PNA was defined based on: neck diameter >28 mm, length <15 mm, angulation >60o, and circumferential thrombus and/or calcification >50%. The aortic neck scoring system was calculated. Multiple logistic regression analysis with a forward likelihood ratio method adjusted for age and gender was undertaken.

RESULTS

Three hundred seventeen patients (96% males, mean age 72.4±9 years, 80% elective) were follow-up for a mean of 23.4 months (range, 3-86 months). No differences were observed in demographics and co-morbidities between the two groups (group A: 134, 42% vs. group B: 183, 58%). Hostile PNA was present in 147/317 (46%) patients and significantly more likely to be present in group B (P<0.001). In group B the aortic neck score was higher (P<0.001), the likelihood for having hostile PNA increased for neck diameter by 2.2-fold (OR 2.2, P=0.013, 95% CI: 1.18-4.03), length by 2.3-fold (OR 2.3, P=0.012, 95% CI: 1.20-4.51), angle by 4.8-fold (OR 4.8, P=0.002, 95% CI: 1.79-13.24) and presence of thrombus by 1.5-fold (OR 1.5, P=0.037, 95% CI: 1.45-10.34). No association existed for neck calcification (P=0.071). Technical success, adjunctive procedures, perioperative characteristics and outcomes were comparable in friendly and hostile PNAs.

CONCLUSIONS

PNA hostility is more likely in AAA with diameter >55 mm but with the use of newer generation endografts this did not influence the short- and mid-term EVAR outcomes. Longer follow-up is needed for a more definite conclusion.

Editor's Choice - The Implications of Non-compliance to Endovascular Aneurysm Repair Surveillance: A Systematic Review and Meta-analysis

OBJECTIVE/BACKGROUND

Increasingly, reports show that compliance rates with endovascular aneurysm repair (EVAR) surveillance are often suboptimal. The aim of this study was to determine the safety implications of non-compliance with surveillance.

METHODS

The study was carried out according to the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic search was undertaken by two independent authors using Embase, MEDLINE, Cochrane, and Web of Science databases from 1990 to July 2017. Only studies that analysed infrarenal EVAR and had a definition of non-compliance described as weeks or months without imaging surveillance were analysed. Meta-analysis was carried out using the random-effects model and restricted maximum likelihood estimation.

RESULTS

Thirteen articles (40,730 patients) were eligible for systematic review; of these, seven studies (14,311 patients) were appropriate for comparative meta-analyses of mortality rates. Three studies (8316 patients) were eligible for the comparative meta-analyses of re-intervention rates after EVAR and four studies (12,995 patients) eligible for meta-analysis for abdominal aortic aneurysm related mortality (ARM). The estimated average non-compliance rate was 42.0% (95% confidence interval [CI] 28-56%). Although there is some evidence that non-compliant patients have better survival rates, there was no statistically significant difference in all cause mortality rates (year 1: odds ratio [OR] 5.77, 95% CI 0.74-45.14; year 3: OR 2.28, 95% CI 0.92-5.66; year 5: OR 1.81, 95% CI 0.88-3.74) and ARM (OR 1.47, 95% CI 0.99-2.19) between compliant and non-compliant patients in the first 5 years after EVAR. The re-intervention rate was statistically significantly higher in compliant patients from 3 to 5 years after EVAR (year 1: OR 6.36, 95% CI 0.23-172.73; year 3: OR 3.94, 85% CI 1.46-10.69; year 5: OR 5.34, 95% CI 1.87-15.29).

CONCLUSION

This systematic review and meta-analysis suggests that patients compliant with EVAR surveillance programmes may have an increased re-intervention rate but do not appear to have better survival rates than non-compliant patients.

Preliminary experience with the Endurant II short form stent-graft system

BACKGROUND

The aim of this study was to evaluate our preliminary experience with the use of the Endurant II short form (IIs) stent-graft in the treatment of abdominal aortic aneurysms (AAAs).

METHODS

Between November 2014 and November 2015, 79 patients were consecutively treated with the Endurant IIs stent-graft at three European vascular centers. Early (30-day) results in terms of technical success, limb occlusion, major morbidity, and mortality were analyzed. Estimated 1-year outcomes in terms of survival, freedom from type I endoleak, freedom from limb occlusion, and freedom from any device-related reinterventions were assessed with Kaplan-Meyer method. Factors affecting 1-year freedom from type I endoleak were analyzed by log-rank test and by Cox regression test for multivariate analysis.

RESULTS

Intraoperative technical success was achieved in all cases. Thirty-day mortality was 1.3% (one death due to cardiac failure). Early type I endoleak was detected in three patients (3.8%). During the follow-up (mean duration 6.7 months; range 1-14), two type I endoleaks resolved spontaneously. No limb occlusions or aneurysm-related reinterventions were recorded. Estimated survival, freedom from type I endoleak, freedom from limb occlusions, and freedom from any device-related reinterventions rates at 1 year were 96%, 96.6%, 100%, and 100%, respectively. Adoption of chimney technique significantly affected 1-year freedom from type I endoleak (P≤0.001).

CONCLUSIONS

Preliminary use of the new Endurant IIs stent-graft is safe and effective in endovascular repair of AAAs (EVAR) without early limb occlusions. Further studies with larger population sizes and longer follow-up are needed to evaluate mid- and long-term results.

One Year Outcome Using Newer Generation Endografts: A National Multicenter Study on Real Word Practice

BACKGROUND

The aim of this study was to assess the 1 year outcomes following endovascular aortic aneurysm repair (EVAR) with the use of newer generation endografts.

METHODS

Retrospective analysis was conducted of prospectively collected multicenter data from 385 EVARs. Newer endografts were defined as those introduced after 2004. Patients' demographics and comorbidities, type of operation, and abdominal aortic aneurysm (AAA) morphological characteristics were analyzed. Computer tomography was performed 1 month and 1 year post-EVAR.

RESULTS

Mean age of the patients was 71.3 years; in 335 cases the intervention was elective. The mean AAA sac, neck diameter, and length were 57.15, 24.5, and 28.97 mm, respectively. Ninety-four endoleaks were recorded in 92 patients (25%), including 11 type 1a (T1aE), 3 type 1b, and 78 type 2 (T2E) endoleaks. On logistic regression analysis, neck diameter >30 mm (P = 0.032) and initial AAA sac diameter >55 mm (P = 0.031) were associated with T1aE. No association was found with T2E. Overall, 107 (27%) patients had sac expansion at 1 year associated with the presence of T2E (P = 0.019). No association was observed between T1aE or T2E and specific endograft.

CONCLUSIONS

Newer generation endografts show very satisfactory performance even in difficult anatomies. T1aE was associated with initial sac and neck diameter, while AAA sac expansion was associated with the presence of T2E.

Outcomes of Endurant stent graft in narrow aortic bifurcation

OBJECTIVE

The purpose of this study was to compare the outcomes obtained with Endurant stent graft in the early and midterm period in the treatment of patients with narrow aortic bifurcation vs patients with standard aortic bifurcation.

METHODS

Data were prospectively collected from 817 patients with abdominal aortic aneurysm treated between November 2007 and August 2014 with the Endurant stent graft at our center. There were 87 patients (10.6%) with a narrow aortic bifurcation (≤20 mm; NA group). The remaining 730 patients (89.4%) had a standard aortic bifurcation (SA group). Early and estimated 3-year outcomes were evaluated in these patients in terms of survival, freedom from any device-related reinterventions, and freedom from graft thrombosis. Univariate and multivariate analyses in the NA group were performed to detect possible predictors for poor outcomes.

RESULTS

The two groups were similar in terms of demographics, preoperative diagnostic assessment, and intraoperative data. In 211 of 817 patients (25.8%), an adjunctive iliac limb stenting by balloon-expanding stents was performed. Overall, 41 patients in the NA group (47.1%) underwent iliac limb stenting, whereas an iliac stent was implanted in just 170 patients (23.3%) in the SA group (P < .001). The mean follow-up was 16.3 months (range, 1-73 months). The estimated 3-year survival rate was similar between the two groups (87.2% in the NA group vs 80.8% in the SA group; P = .84). Furthermore, the estimated freedom from any device-related reinterventions was 92.9% in the NA group and 85.5% in the SA group (P = .1). Finally, the estimated 3-year freedom from graft thrombosis was 96.9% in the NA group and 94.8% in the SA group (P = .79). In the NA group at univariate and multivariate analyses, none of the examined preoperative or intraoperative factors were independent predictors of poor outcomes.

CONCLUSIONS

Use of bifurcated Endurant stent graft, combined in almost half of the patients with narrow aortic bifurcation with additional aortoiliac stent placement, is feasible and safe. Early and midterm outcomes are similar to those obtained in non-narrow aortic bifurcation.

Systematic review and meta-analysis of migration after endovascular abdominal aortic aneurysm repair

Aim

To identify patients who are under higher threat for migration because of an old generation stent graft application.

Methods

A systematic review and meta-analysis of the literature was undertaken to identify all studies which included older generation endografts and data reporting on graft migration after EVAR. Outcome data were pooled and combined, and were calculated using fixed or random effects models.

Results

From 2000 to 2014, 22 retrospective studies were identified reporting on stent- graft migration after EVAR (8.6%). From those patients, 39% received re-intervention with the mean time of identification ranging from 12 to 36 months. Six of these retrospective nonrandomized studies were eligible for meta-analysis. AAA diameter (AAA diameter: 0.719 mm; 95% confidence interval [CI]: 0.00065–1.4384 mm; p = 0.00497) and neck length (neck length: 4.36 mm; 95% CI: 1.3277–7.394; p = 0.0048) were the only significant factors associated with stent- graft migration. Neck diameter and neck angulation did not have any important influence on stent-graft migration.

Conclusions

Patients with large AAA and short necks who were treated with older generation stent grafts such as AneurX and Talent are in higher risk for endograft migration than others. Stent- graft migration consists of an insidious and underestimated threat.