Evolution of the Proximal Sealing Rings of the Anaconda Stent-Graft After Endovascular Aneurysm Repair

Endograft Anaconda in Endovascular Aneurysm Repair: A Systematic Review of Literature and Meta-Analysis

BACKGOUND

The number of endovascular abdominal aortic aneurysm repairs (EVARs) has surpassed the number of open surgical repair of AAAs worldwide with a great variety of endografts being available. The aim of this study is to conduct a systematic review of the literature and meta-analysis of studies reporting patients with infrarenal abdominal aortic aneurysm (AAA) subjected to EVAR with the Anaconda endograft.

METHODS

We performed a systematic review of multiple electronic databases for studies including patients with infrarenal AAA who were subjected to elective EVAR with Anaconda endograft exclusively. We conducted a proportional meta-analysis cumulating the results of the included studies. The endpoints were first month overall mortality, first and second-year survival after EVAR, AAA-related deaths, incidence of endoleaks, endograft migration, endograft occlusion, open conversion, and primary and secondary technical success. The mean value for each separate studied factor was calculated, and the respective percentage or incidence was extracted so that it can be compared to endograft outcome studies in the literature. We assessed the methodologic quality of studies by using the Briggs Institute critical appraisal tool.

RESULTS

Seven observational studies were found including 954 patients (males 91.9%, mean age 73.38 ± 6.97 years). The mean transverse diameter of AAAs was 56.83 ± 9.97 mm. The mean proximal aortic neck diameter and length were 23.06 ± 3.33 mm and 24.14 ± 12.16 mm, respectively. Increased aortic neck calcification and aortic neck thrombus were present in 12.5% of patients. The 30-day overall mortality post-EVAR was 1.3%, 1 and 2-year survival rates were 95.9% and 91.4%, respectively. The mean follow-up period in the studies was 46.59 ± 15.5 months. AAA-related mortality was 1.3%. Primary technical success was 97.9% and secondary success was 99.3%. Open conversion was required in 3.4% of all patients (0.6% during the primary operation [Prim. Op]). The most common endoleak was type II, reported in 17.4% of all patients. Early type Ia endoleak was reported in 1.5% of patients and late type Ia in 1.7%. Overall, 2 endoleaks type III and 1 type IV were reported. Endograft migration occurred in 1.7% of patients. Main body and/or one/both iliac legs thrombotic occlusion was found totally in 7.6% of patients (5 main body occlusions and 64 iliac leg occlusions).

CONCLUSIONS

The use of Anaconda endograft in electively treated patients with infrarenal AAAs presented good results with high technical success and low postoperative and mid-term complications, except for an increased incidence of stent-graft thrombosis, which seems to be the "Achilles heel" of the device.

Renal and Visceral Artery Configuration During the First Year of Follow-Up After Fenestrated Aortic Aneurysm Repair Using the Anaconda Stent-graft: A Prospective Longitudinal Multicenter Study With ECG-Gated CTA Scans

OBJECTIVE

The performance of fenestrated endovascular aortic aneurysm repair (FEVAR) may be compromised by complications related to the dynamic vascular environment. The aim of this study was to analyze the behavior of FEVAR bridging stent configurations during the cardiac cycle and during follow-up to improve our understanding on treatment durability.

DESIGN

Twenty-one patients presenting with complex abdominal aortic aneurysms (AAAs; 9 juxtarenal/6 pararenal/3 paravisceral/1 thoracoabdominal aortic aneurysm type IV), treated with a fenestrated Anaconda (Terumo Aortic, Inchinnan, Scotland, UK) with Advanta V12 bridging stents (Getinge, Merrimack, NH, USA), were prospectively enrolled in a multicenter observational cohort study and underwent electrocardiogram (ECG)-gated computed tomographic angiography (CTA) preoperatively, at discharge, 7-week, and 12-month follow-ups.

METHODS

Fenestrated endovascular aortic aneurysm repair stability was assessed considering the following variables: branch angle as the angle between the aorta and the target artery, end-stent angle as the angle between the end of the bridging stent and the native artery downstream from it, curvature and tortuosity index (TI) to describe the bending of the target artery. Body-bridging stent stability was assessed considering bridging stent flare lengths, the distances between the proximal sealing stent-ring and fenestrations and the distance between the fenestration and first apposition in the target artery.

RESULTS

Renal branch angles significantly increased after FEVAR toward a perpendicular position (right renal artery from median 60.9°, inter quartile range [IQR]=44.2-84.9° preoperatively to 94.4°, IQR=72.6-99.8°, p=0.001 at 12-month follow-up; left renal artery [LRA], from 63.7°, IQR=55.0-73.0° to 94.3°, IQR=68.2-105.6°, p<0.001), while visceral branch angles did not. The mean dynamic curvature only decreased for the LRA from preoperative (3.0, IQR=2.2-3.8 m-1) to 12-month follow-up (1.9, IQR=1.4-2.6 m-1, p=0.027). The remaining investigated variables did not seem to show any changes over time in this cohort.

CONCLUSIONS

Fenestrated endovascular aortic aneurysm repair for complex AAAs using the Anaconda fenestrated stent-graft and balloon-expandable Advanta V12 bridging stents demonstrated stable configurations up to 12-month follow-up, except for increasing renal branch angles toward perpendicular orientation to the aorta, yet without apparent clinical consequences in this cohort.

CLINICAL IMPACT

This study provides detailed information on the cardiac-pulsatility-induced (dynamic) and longitudinal geometry deformations of the target arteries and bridging stents after fenestrated endovascular aortic aneurysm repair (FEVAR) up to 12-month follow-up. The configuration demonstrated limited dynamic and longitudinal deformations in terms of branch angle, end-stent angle, curvature, and tortuosity index (TI), except for the increasing renal branch angles that go toward a perpendicular orientation to the aorta. Overall, the results suggest that the investigated FEVAR configurations are stable and durable, though careful consideration of increasing renal branch angles and significant geometry alterations is advised.

Scholten GA, Reijnen MM, Slump CH. The influence of electrocardiogram-gated computed tomography reconstruction into 8 or 10 cardiac phases on cardiac-pulsatility-induced motion quantification of stent grafts in the aorta

Objective

The goal of this study was to determine to what extent aortic stent graft motion quantification is comparable between electrocardiogram (ECG)-gated computed tomography (CT) scans with reconstructions into 8 and 10 cardiac phases on CT scanners from two different vendors.

Methods

An experimental setup that induces motion of an aortic stent graft, according to a predefined aortic blood pressure wave, was placed in two CT scanners of different vendors. The stent graft motion was captured using an ECG-gated CT technique and quantified using dedicated analysis algorithms. The calculated motion amplitudes and total traveled path lengths of stent segmentations were compared between scans reconstructed into 8 and 10 phases and between the scanners, after validation with sensor measurements and repeated measurements.

Results

No difference in motion amplitudes in z-direction (craniocaudal direction) was observed between the reconstructions into 8 and 10 phases (0.02 mm; 95% confidence interval [CI], -0.01 to 0.05 mm; P = .358). The z-amplitudes differed by 0.04 mm (95% CI, 0.01-0.07 mm; P = .003) between the different CT scanners. Path lengths differed 0.07 mm (95% CI, 0.01-to 0.13 mm; P = .013) between the reconstructions into 8 and 10 phases and 0.13 mm (95% CI, 0.06-0.17 mm; P < .001) between the different scanners.

Conclusions

The motion amplitudes can accurately be compared between 8 and 10 phases and between the two scanners, without differences larger than the voxel size of 0.3 × 0.3 × 0.5 mm. Clinical motion analysis results of different ECG-gated CT scans and CT scanners can be compared up to the accuracy of the CT scan.

Fractured Sealing Rings in a Fenestrated Anaconda Stent-Graft

An 81 year-old man presented with an asymptomatic juxtrarenal abdominal aortic aneurysm and was subsequently treated with a fenestrated endovascular Anaconda stent-graft. Surveillance imaging within the first postoperative year demonstrated a lower proximal sealing ring fracture. In the second postoperative surveillance year, the upper proximal sealing ring was also fractured with extension of the wire into the right paravertebral space. Despite these sealing ring fractures, there were no endoleak nor visceral stent complications and the patient continued on standard surveillance protocols. There are an increasing number of reports of fractured proximal sealing rings with the fenestrated Anaconda platform. Those analysing the surveillance scans of patients treated with this device should stay vigilant for the development of this complication.

Differences in Cardiac-Pulsatility-Induced Displacement and Geometry Changes between the Cook ZBIS and Gore IBE: Postoperative Comparison Using ECG-Gated CTA Scans

To what extent the stentgraft design of iliac branch devices (IBDs) relates to dynamic deformation is currently unknown. Therefore, this study aimed to quantify and compare displacement and geometry changes during the cardiac cycle of two common IBDs. This paper presents a two-center trial with patients treated with a Zenith bifurcated iliac side (ZBIS) or Gore iliac branch endoprosthesis (IBE). All patients underwent a retrospective electrocardiogram (ECG)-gated computed tomographic angiography (CTA) during follow-up. Cardiac-pulsatility-induced displacement was quantified for the following locations: (neo) bifurcation of the aorta, IBD flow divider, distal markers of the internal iliac artery (IIA) component and first IIA bifurcation. Geometrical parameters (length, tortuosity index, curvature and torsion) were quantified over centerlines. Displacement was more pronounced for the IBE than the ZBIS, e.g., craniocaudal displacement of 0.91 mm (0.91-1.13 mm) vs. 0.57 mm (0.40-0.75 mm, p = 0.004), respectively. The IBDs demonstrated similar geometrical parameters in the neo-common iliac artery and distal IIA, except for the larger dynamic curvature and torsion of the distal IIA in IBEs. The IBEs showed more dynamic length and curvature change compared to the ZBIS in the stented IIA. The IIA trajectory showed more pronounced deformation during the cardiac cycle after placement of an IBE than a ZBIS, suggesting the IBE is more conformable than the ZBIS.

Abdominal Aortic Aneurysm: Can the Anaconda™ Custom-Made Device Deliver? An International Perspective

Introduction

Since the introduction of endovascular aortic repair (EVAR), it has demonstrated excellent clinical outcomes and has replaced open surgical repair (OSR) in the treatment of abdominal aortic aneurysms (AAA). AAA is a life-threatening abnormal dilation of the abdominal aorta to 1.5 times its normal diameter. Several commercial EVAR devices exist on the global market, with the Terumo Aortic Fenestrated Anaconda™ graft showing superiority. In this study, we sought to provide an international perspective using multicenter-multinational data on the Anaconda™ device characteristics, design, and delivery, and discuss relevant literature.

Materials and Methods

This study represents a cross-sectional international analysis of custom-made fenestrated Anaconda™ device. Ethical and legal approval for data collection was obtained from each of the local authorities. For the statistical analysis, SPSS 28 for Windows and R were utilized. Pearson’s chi-square analysis was used to assess differences in cumulative distribution frequencies between select variables. Statistical significance for all two-tailed tests was set at p < 0.05.

Results

A total of 5,030 Anaconda™ devices were implanted during the 9-year study period in 27 countries spanning 6 continents. The predominant device category was bifurcate (83.6%), whereas the most common proximal ring stent configuration being standard (64.5%). All devices were delivered within 8 weeks of diagnosis, with most being implanted within 6–8 weeks (55.4%). The Anaconda™ was indicated in the 3,891 (77.4%) patients due to competitor rejection/inability to treat unsuitable/complex aortic anatomy. In the remaining 1,139 (22.6%) patients, it was utilized based on surgeon preference. Almost all devices (95%) were delivered along with a prototype. Of the total 5,030 Anaconda™ devices, 438 (8.7%) used 0–1 fenestrations, 2,349 (46.7%) used 2–3, while 2,243 (44.6%) utilized 4, 5, or 6 fenestrations.

Discussion

The Terumo Aortic Fenestrated Anaconda™ device features a highly unique and innovative design that enables it to treat highly complex aortic anatomy while achieving excellent results. The Anaconda™’s custom-made approach allows it to be tailored to individual patient anatomy, in addition to the device prototype provided by Terumo Aortic optimize clinical outcomes. Finally, the fenestrated Anaconda™ is a highly versatile device offering a wide range of device categories, configurations, and sizes.

Nineteen-year outcomes with the Anaconda stent graft system from two tertiary centers

OBJECTIVE

The Anaconda stent graft device presents peculiar and unique features in its design and deployment sequence, available on the market for many years with minor modifications, among different generations. The aim of this study was to assess the long-term, real-life, outcomes obtained in two high-volume centers with this endograft for infrarenal aortic aneurysms treatment over a period of 19 years.

METHODS

All patients treated with the investigated device between 2000 and 2019, with at least 1 year of follow-up, were entered into a prospective database and data were reviewed retrospectively. The long-term results were assessed according to the Kaplan-Meier method. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes were freedom from late reintervention, freedom from late conversion to open repair, freedom from late limb occlusion, and freedom from late EVAR failure.

RESULTS

A total of 260 consecutive patients were treated during the study period. Technical success was achieved in 98.5% (256/260) of the cases. Two perioperative deaths (0.8%) and four major complications (1.5%) were recorded. At a mean follow-up of 54 ± 38 months (summary follow-up index = 0.86), the late survival estimate was 94.8% at 1 year, 75.2% at 5 years, 50.5% at 10 years, and 43.3% at 13 years, with no case of late AAA rupture or late AAA-related death. Late freedom from conversion was 99.2% at 1 year, 96.9% at 5 years, 94.0% at 10 years, and 94.0% at 13 years. Freedom from late limb thrombosis was 96.8% at 1 year and 91.0% at 5, 10, and 13 years. Estimates of freedom from late reintervention was 95.6% at 1 year, 87.0% at 5 years, 77.4% at 10 years, and 77.4% at 13 years. Estimates of limb thrombosis at 11 years were significantly different in patients receiving or not intraoperative iliac kissing balloon maneuver with noncompliant angioplasty catheters (98.0% vs 88.4%; P = .029).

CONCLUSIONS

The Anaconda stent graft demonstrated effective and durable outcomes for AAA treatment over a 19-year period, with no case of late AAA rupture or AAA related death in the studied population. Late limb occlusion was the leading cause of reintervention; however, a positive prevention strategy was found in intraoperative kissing balloon, which was associated with significant reduced rate of iliac thrombosis over time.

Efficiently Simulating an Endograft Deployment: A Methodology for Detailed CFD Analyses

Numerical models of endografts for the simulation of endovascular aneurysm repair are increasingly important in the improvement of device designs and patient outcomes. Nevertheless, current finite element analysis (FEA) models of complete endograft devices come at a high computational cost, requiring days of runtime, therefore restricting their applicability. In the current study, an efficient FEA model of the Anaconda™ endograft (Terumo Aortic, UK) was developed, able to yield results in just over 4 h, an order of magnitude less than similar models found in the literature. The model was used to replicate a physical device that was deployed in a 3D printed aorta and comparison of the two shapes illustrated a less than 5 mm placement error of the model in the regions of interest, consistent with other more computationally intensive models in the literature. Furthermore, the final goal of the study was to utilize the deployed fabric model in a hemodynamic analysis that would incorporate realistic fabric folds, a feature that is almost always omitted in similar simulations. By successfully exporting the deployed graft geometry into a flow analysis, it was illustrated that the inclusion of fabric wrinkles enabled clinically significant flow patterns such as flow stagnation and recirculation to be detected, paving the way for this modelling methodology to be used in future for stent design optimisation.

Geometrical changes in Anaconda endograft limbs after endovascular aneurysm repair: A potential predictor for limb occlusion

The emergence of limb occlusion after endovascular aneurysm repair may be related to the conformational changes between the endograft structure and the patient's anatomy. This study analyzed detailed geometric changes of Anaconda endograft (Terumo Aortic, Inchinnan, Scotland, UK) limbs during the cardiac cycle-based computed tomography on serial imaging after graft implantation. Fifteen patients (mean age 72.8 ± 3.7 years; 14 men) underwent postoperative electrocardiogram-gated computed tomography scans according to a prospective study design between April 2014 and May 2017. Changes in curvature, length of the limbs, and distances between successive stent rings (inter-ring distance) of the endograft limbs during a 2-year follow-up period were quantified using meticulous image processing methods involving image registration, centerline extraction, and model-based stent-ring segmentation. From discharge to 24 months, mean curvature increased significantly by 9.6 m^-1 (standard deviation [SD], 11.1 m^-1; 95% confidence interval [CI], 3.4 to 15.8 m^-1; P = .002) for the right limbs and by 6.1 m^-1 (SD 9.4 m^-1; 95% CI, 0.8 to 11.5 m^-1; P = .21) for the left limbs. The length of the right limbs decreased significantly, by 9.5 mm (SD 7.6 mm; 95% CI, 3.5 to 15.6 mm; P = .002); the length of the left limbs decreased by 10.1 mm (SD 5.1 mm; 95% CI, 5.9 to 14.2 mm; P < .001). The minimal inter-ring distance decreased by 0.36 mm (SD 0.26 mm; 95% CI, 0.17 to 0.55 mm; P < .001) for the right limbs and 0.35 mm (SD 0.19 mm; 95% CI, 0.21 to 0.49 mm; P < .001) for the left limbs. Cardiac pulsatility-induced changes in curvature, limb length, and inter-ring distance were negligible (2%, 0.3% and 0.3%, respectively). Changes in the geometry of the Anaconda endograft limbs after endovascular aortic aneurysm repair were observed during a 2-year follow-up manifest as an increase in curvature, shortening of the stent-graft limbs, and a corresponding decrease in inter-ring distance. These stent-graft conformational changes could result in inward folding of the graft fabric, which may relate to the emergence of limb occlusion. Further investigation of these metrics in a larger cohort involving patients with and without occlusions may allow determination of their predictive value.

Outcomes of Endovascular Aneurysm Repair Using the Anaconda Stent-Graft

Purpose: To report outcomes of elective endovascular aneurysm repair (EVAR) using the Anaconda stent-graft in a tertiary vascular center. Materials and Methods: A retrospective study was conducted of 271 patients (mean age 71.5 years; 260 men) who underwent elective EVAR for abdominal aortic aneurysm using the Anaconda stent-graft from January 2006 to January 2017. Median aneurysm diameter was 58 mm (range 50-90). All patients were anatomically suitable for EVAR according to the 2003 version of the instructions for use. Follow-up included computed tomography angiography at 1, 6, and 12 months and yearly thereafter for the first 4 years and then every 2 years. Primary outcomes included technical success and 30-day aneurysm-related mortality and complications; secondary outcomes were overall and aneurysm-related mortality and aneurysm-related morbidity in follow-up. Results: The Anaconda stent-graft was implanted successfully in all patients. Primary and secondary technical success rates were 99.6% and 100%, respectively. Three patients (1.1%) died within 30 days of causes unrelated to the aneurysm, while 15 patients (5.5%) suffered perioperative complications. Median follow-up was 72 months (range 14-141). The overall type I endoleak rate was 4.7% (11 proximal, 2 distal). Late aneurysm-related complications were observed in 48 patients (17.3%); aneurysm-related mortality was 1.4% (n=4). Non-aneurysm-related mortality was 21.0% (n=57). Freedom from reintervention was 95.2% at 1 year, 98% at 2 years, and 90% at 6 years. There was no significant difference in the overall limb graft occlusion rate between the second- and third-generation devices. Conclusion: Results in our cohort study demonstrate that the Anaconda stent-graft has satisfactory early and late results with low aneurysm-related mortality.

Outcomes after treatment of complex aortic abdominal aneurysms with the fenestrated Anaconda endograft

OBJECTIVE

To date, information on the fenestrated Anaconda endograft is limited to case series with a small sample size. This study was performed to assess the technical and clinical outcome of this device in a large international case series.

METHODS

All worldwide centers having treated more than 15 complex abdominal aortic aneurysms (AAA) or type IV thoracoabdominal aortic aneurysm patients with the fenestrated Anaconda endograft were approached. Main outcome parameters were procedural technical success, postoperative and follow-up clinical outcome for endoleaks, target vessel patency, reintervention rate, and patient survival.

RESULTS

Three hundred thirty-five consecutive cases treated between June 2010 and May 2018 in 11 sites were included. Patients were treated for a short neck infrarenal (n = 98), juxtarenal (n = 191), suprarenal AAA (n = 27), or type IV thoracoabdominal aortic aneurysm (n = 19). Mean age was 73.6 ± 4.6 years (292 male). Endografts contained a total of 920 fenestrations, with a mean of 2.7 ± 0.8 fenestrations per case. Technical success was 88.4% (primary, 82.7%; assisted primary 5.7%). In 6.9% of cases, a procedural type IA endoleak was observed, spontaneously disappearing in 82.6% during early follow-up. The development of a type IA endoleak was associated with greater neck angulation (odds ratio [OR], 0.94; P = .01), three fenestrations (OR, 42.7; P = .01) and the presence of augmented proximal rings (OR, 0.17; P = .03). Median follow-up was 1.2 years (interquartile range, 0.4-2.6). The mean estimated glomerular filtration rate deteriorated from 67.6 ± 19.3 mL/min/1.73 m² preoperatively to 59.3 ± 22.7 mL/min/1.73 m² at latest follow-up (P = .00). The freedom from AAA growth were 97.9 ± 0.9% (n = 190) and 86.4 ± 3.0% (n = 68), with a freedom from AAA rupture of 99.7 ± 0.3% (n = 191) and 99.1 ± 0.7% (n = 68), at 1 and 3 years, respectively. The endoleak-free survival, excluding spontaneously resolved procedural endoleaks, at 1 and 3 years was 73.4 ± 2.6 (n = 143) and 65.6 ± 3.4% (n = 45), respectively. The target vessel patency at one and three years were 96.4 ± 0.7% (n = 493) and 92.7 ± 1.4% (n = 156), respectively. A total of 75 reinterventions were done in 64 cases (19.1%), of which 25 cases for an endoleak. The reintervention-free survival at 1 and 3 years were 83.6 ± 2.2% (n = 190) and 71.0 ± 3.7% (n = 68), respectively. No deaths during procedure, extending within 24 hours postoperatively, were observed. Within 30 days 14 patients (4.2%) died and during follow-up another 39 patients (11.6%) died. Three deaths were considered AAA related (one rupture, one endograft infection, and one bilateral renal artery occlusion). The estimated cumulative survival at 1 and 3 years were 89.8 ± 1.8% (n = 191) and 79.2 ± 3.0% (n = 68), respectively.

CONCLUSIONS

The custom-made fenestrated Anaconda endograft is a valuable option for the treatment of a complex AAA. A procedural type IA endoleak is seen relatively frequently, but spontaneously resolves in most cases.

Geometric Remodeling of the Perirenal Aortic Neck at and Adjacent to the Double Sealing Ring of the Anaconda Stent-Graft After Endovascular Aneurysm Repair

Purpose: To evaluate if the radial force of the double sealing ring of the Anaconda stent-graft induces dilatation in the perirenal aortic neck adjacent to the rings. Materials and Methods: This study evaluated the serial electrocardiogram-gated computed tomography scans of 15 abdominal aortic aneurysm patients (mean age 72.8±3.7 years; 14 men) who were treated electively using an Anaconda stent-graft. Follow-up scans were conducted before discharge and at 1, 6, 12, and 24 months after endovascular repair. Diameter and area were assessed perpendicular to the aortic centerline along the perirenal aortic neck, which was subdivided into 3 zones: the suprastent, the stent, and the infrastent zones. Measurements were performed independently by 2 experienced observers using dedicated 3-dimensional image processing software. Results: Between discharge and the 2-year follow-up the diameter and area remained stable in the suprastent zone [average diameter change: −0.1±0.4 mm (−0.4%±1.7%), p=0.893; average area change: −2.9±17.2 mm² (−0.7%±3.4%), p=0.946], increased in the stent zone [average diameter change: +1.9±1.0 mm (+7.3%±4.0%), p<0.001; average area change: +84.3±48.3 mm² (+15.5%±8.7%), p<0.001], and diverged in the infrastent zone [average diameter change: −0.8±2.2 mm (−2.3%±7.4%), p>0.99; average area change: −34.6±102.3 mm² (−4.1%±14.8%), p>0.99; increased in 4 patients, decreased in 9 patients]. Conclusion: After Anaconda implantation the infrarenal aortic neck accommodated to the expansion of the sealing rings at the stent zone. Below the stent zone the neck diameter decreased in the majority of patients, while an increase was related to downstream displacement of the main body. A decrease in size in the infrastent zone may contribute to durable sealing and fixation. A personalized follow-up scheme based on geometric neck remodeling should be feasible if our observations are confirmed in larger, long-term studies.

Endovascular Management of a Distally Migrated Bifurcated Endograft with a New Bifurcated Endograft

A 75-year-old man presented with abdominal and lumbar pain 6 years after previous endovascular repair of an abdominal aortic aneurysm. At the time of the initial operation, the aneurysm measured 6.0 cm in maximum diameter and a bifurcated Anaconda (Vascutek) endograft had been implanted. This time, computed tomography showed a distally migrated endograft which had been folded within the sac and the aneurysm measured 8.4 cm in maximum diameter. We opted to treat this by endovascular means deploying a new bifurcated endograft with suprarenal fixation within the old one. We consider the different management options and discuss the associated technical difficulties.