Invited commentary

Appropriate case selection is a critical step in securing good long-term outcomes with endovascular repair for abdominal aortic aneurysm disease. Many reports have documented a relatively high migration rate associated with AneuRx stent grafts, with predictive factors mostly related to aneurysm neck anatomy. The current manuscript confirms the strong association between unsatisfactory aneurysm neck anatomy and a high risk of migration of the AneuRx device. Neck angulation was the most commonly noted unfavorable feature and found to be highly predictive of migration risk. The results would support a word of caution against using the AneuRx device in patients with unsuitable necks, especially those with a significant angulation of the neck to the aneurysm body.

One may quite reasonably disagree with the conclusion of the authors that the data support “the use of the AneuRx device as a feasible alternative to open repair even in those patients with challenging neck characteristics.” A graft-related complication rate of 64% in this patient subgroup can hardly justify this conclusion.

Open repair is not the only other option, either. The performance of endografts clearly differs in certain challenging anatomic situations and some designs, like the Ancure device, have been found to be particularly well suited for difficult neck anatomy.1 Other currently available devices, with active fixation or more flexible construction, can still be used in this situation with more acceptable results. The lack of ruptures or aneurysm-related deaths in a selected group representing 14% of the total experience is certainly not convincing enough. A very high reintervention rate of 52% and increased surveillance and heightened concern may be too high a price to pay for using AneuRx in these cases.

The data presented here also serve to remind us that unsatisfactory outcomes obtained under certain adverse conditions should not be used to characterize the performance of a device in all situations. A relatively low migration risk of 6% at 4 years in patients with favorable neck anatomy can be viewed as reassurance that acceptable results can be expected by using the AneuRx device in patients who fit the revised instructions for use. Appropriate case selection would thus allow the use of the AneuRx device safely.