Late Type IIIa Endoleak Despite Adequate Component Overlap after AFX2 EVAR: A Report of Two Cases

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Late type IIIa endoleak after AFX2 endovascular aneurysm repair for infrarenal abdominal aortic aneurysm (n=2). Intervention: Endovascular relining (focal cuff relining with VELA extension cuffs or complete endograft relining with Endurant system) after AFX2 EVAR. Primary outcome: Complete resolution of type IIIa endoleak and exclusion of the aneurysm sac.

Q: What does this research mean for the field?

AFX2 endovascular aneurysm repair can result in late type IIIa endoleaks from component uncoupling years after implantation despite achieving recommended initial component overlap. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Noriyuki Yokoyama; Takamitsu Tatsukawa; Kyokei Fuchizawa; Jeong A Lee; Kouji Kagawa; Daita Kobayashi; Nobuyuki Akasaka; Hideyuki Harada

doi:10.3400/avd.cr.26-00144

January 1, 2026Annals of Vascular DiseasesOpen Access

Late Type IIIa Endoleak Despite Adequate Component Overlap after AFX2 EVAR: A Report of Two Cases

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Key result

AFX2 EVAR can develop late type IIIa endoleaks beyond 6 years despite extensive overlap.

n=2

Why the study?

Late type IIIa endoleak is a recognized complication after AFX2 endovascular aneurysm repair that can occur despite adequate initial component overlap.

Key Points

To describe two cases of late type IIIa endoleak caused by modular component uncoupling 6 and 7 years after AFX2 endovascular aneurysm repair despite adequate initial overlap.
Reported 2 clinical cases presenting with late modular junction failure 6 and 7 years after AFX2 endovascular aneurysm repair (EVAR).
Evaluated graft stability and endoleaks using computed tomography angiography (CTA), serial computed tomography (CT), duplex ultrasonography, and intraoperative angiography.
Both patients developed late junctional separation despite an initial component overlap of 47 mm, which met both the prior 30–40-mm guidance and the revised criteria requiring 43.5 mm and 45.5 mm.
CTA in Case 1 was inconclusive for uncoupling while duplex ultrasonography detected bidirectional ("to-and-fro") flow; in Case 2, serial CT retrospectively showed progressive sideways displacement before complete uncoupling.
Endovascular reinterventions successfully sealed the leaks using focal VELA extension cuff relining in Case 1 and complete Endurant endograft relining in Case 2.

Study Design

Type

Case Report (n=2)

Multicenter

No

Structured PICO

P

Population

2 octogenarians (1 female, 1 male) with infrarenal abdominal aortic aneurysms who developed late type IIIa endoleaks 6 and 7 years after AFX2 EVAR despite 47-mm initial component overlap.

I

Intervention

Secondary endovascular reintervention tailored to the extent of component failure: focal endovascular relining using two sequential VELA 34-100 mm extension cuffs with balloon molding (Case 1), and complete endograft relining using an Endurant main body (32-16-166 mm) and iliac limbs (16-20-199 mm and 16-20-124 mm) (Case 2).

O

Outcome

Complete resolution of the type IIIa endoleak and complete exclusion of the aneurysm without residual endoleak or persistent sac perfusion on completion angiography and postoperative computed tomography angiography (CTA).surrogate

These cases demonstrate that late type IIIa endoleak and progressive device displacement can occur 6 to 7 years after AFX2 EVAR despite adequate initial component overlap, underscoring the necessity of lifelong multimodal imaging surveillance and tailored endovascular relining.

Limitations

Describes only 2 patients from a single institution and cannot establish the incidence or causal mechanism of late component uncoupling.
The relationship between observed anatomical and configurational features and subsequent component failure remains inferential.
Plain radiography was not performed in either patient.
Serial CT images obtained during the intervening follow-up period were not available for Case 1, limiting longitudinal assessment of component position and configuration.
The relationship between the observed anatomical and configurational features and subsequent component failure remains inferential.

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Implication

Late AFX2 EVAR complications support extended surveillance; leaves open incidence, risk factors, and optimal overlap for durability.

Abstract

Late type IIIa endoleak is a recognized complication of AFX2 (Endologix, Irvine, CA, USA) endovascular aneurysm repair (EVAR). We report 2 cases occurring 6 and 7 years after EVAR despite adequate initial overlap. In Case 1, computed tomography angiography (CTA) did not clearly demonstrate component uncoupling, whereas duplex ultrasonography showed bidirectional (“to-and-fro”) flow and angiography confirmed a type IIIa endoleak. In Case 2, serial computed tomography (CT) retrospectively demonstrated progressive sideways displacement before complete uncoupling. Focal cuff relining and complete endograft relining were performed, respectively. These cases emphasize the need for lifelong surveillance for sac enlargement and changes in endograft configuration after AFX2 EVAR.

Discussion

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Cite This Study

Yokoyama et al. (2026) conducted a case report in Late type IIIa endoleak after AFX2 endovascular aneurysm repair for infrarenal abdominal aortic aneurysm (n=2). Endovascular relining (focal cuff relining with VELA extension cuffs or complete endograft relining with Endurant system) after AFX2 EVAR was evaluated on Complete resolution of type IIIa endoleak and exclusion of the aneurysm sac. AFX2 EVAR resulted in late type IIIa endoleaks at 6 and 7 years in 2 patients despite 47-mm initial overlap, both successfully resolved via focal cuff or complete endograft relining.

synapsesocial.com/papers/6af46d8f7bb3da179b850127 https://doi.org/10.3400/avd.cr.26-00144

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Late Type IIIa Endoleak Despite Adequate Component Overlap after AFX2 EVAR: A Report of Two Cases

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Late Type IIIa Endoleak Despite Adequate Component Overlap after AFX2 EVAR: A Report of Two Cases

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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