Anatomical reconstruction of aortic bifurcation with Endologix AFX Unibody stent-graft in aorto-iliac obstructive disease
Authors: Zaca' Sergio 
Published: September 2024

Introduction and Objective
Endologix AFX stent-graft is advocated for the endovascular aneurysm repair (EVAR) in infrarenal abdominal aortic aneurysm. The off-label adoption of the unimodular bifurcated part of the stent-graft (Unibody) may represent a tailored solution for anatomical reconstruction of aortic bifurcation especially in young patients affected by an aorto-iliac obstructive disease. Aim of our study was to evaluate the outcomes of endovascular reconstruction of aortic bifurcation with AFX Unibody in young patients affected by an obstructive arterial disease that involves the infrarenal aorta and the aortic bifurcation.
Methods
A retrospective review was conducted on 275 patients treated for aorto-ilio-femoral disease with endovascular or hybrid procedures from January 2016 to September 2022 at our department. We considered 31 patients (3 females, 9.7%) affected by infrarenal aortic obstructive lesions that underwent endovascular/hybrid (CFA endarterectomy) reconstruction of aortic bifurcation with AFX Unibody stent-graft. Obstructive lesions were classified with TASC II stages and Rutherford’s clinical categories identified the degree of peripheral arterial disease. Early results were analyzed in terms of 30-day thrombosis, amputation and death. Follow up results were analyzed by life-table analyses (Kaplan-Meier curves) in terms of 3-year primary and secondary graft patency, freedom from reintervention, amputation free survival and overall survival.
Results
Mean age was of 66.1 ± 8.8 years. Most of the lesions were TASC II D (25/31 – 80.6%) and Rutherford’s category 3 was predominant (20/31 – 64.5%). More than two-third of the cases were affected by an obstructive lesion of the aortic bifurcation (24/31 – 77.4%) and in the remaining cases the obstructions involved the infrarenal aorta below the level of renal arteries. Technical success (intention-to-treat analysis) was achieved in all the cases and no open surgical conversions were recorded. Surgical complications rate was 11.1% (3/27 cases) and no post-operative deaths were observed. Ankle-brachial index (ABI) improvement was significant (mean preoperative ABI – postoperative ABI, 0.42 – 0.83, p= .0001). One major amputation and thrombosis (iliac leg acute occlusion) were recorded at 30 days respectively and early survival rate was 100%. The 90.3% (28/31) of the cases have an active follow-up and its mean age was 18.1 ± 12.9 months (Range 1 – 76 months). Estimated overall 3-year survival (all-cause mortality) was 71.3%. Estimated 3-year primary and secondary graft patency were 79.8% and 83.1% respectively. Estimated 3-year freedom from major amputation and freedom from reintervention were 100% and 96.4% respectively.
Conclusions
The off-labeled adoption of AFX Unibody stent-graft in the anatomical endovascular reconstruction of aortic bifurcation for selected patients offered promising results in terms of effectiveness and safety. The reconstruction of the aortic bifurcation allowed surgeons to easily perform further up-and-over procedures especially in young patients with multilevel obstructive disease. Further studies are warranted to analyze the long-term advantages and the cost-effectiveness of the technique.