Abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta to the diameter ≥ 30 mm. The prevalence of AAA is estimated to 1.3-12.5% in men and 0-5.2% in women. AAA formation known risk factors are age (prevalence significantly increases with age, especially > 65 years old), male, family history of AAA, smoking, hypercholesterolemia and hypertension (1, 2). Unruptured AAA symptoms may include atypical abdominal or back pain, and sometimes a palpable pulsatile abdominal mass. However, in most cases a course of the disease is asymptomatic until rupture of AAA. Then an acute abdominal pain and shock usually occur.

According to the European Society of Cardiology Guidelines on the diagnosis and treatment of aortic diseases from 2014, ultrasonography (US) is a recommended AAA screening examination. Screening for AAA with US is recommended in all men > 65 years of age, may be considered in woman > 65 years of age with a history of tobacco smoking. CT and MRI are the reference methods for pre- and postoperative assessment of AAA. Aortography may be a useful imaging modality, if CT and MRI results are unclear and ambiguous.

AAA repair is indicated if it’s diameter exceeds 55 mm or an aneurysm growth exceeds 10 mm/year (3). Although endovascular aortic repair (EVAR) is a safe, effective, and currently the most widely used AAA treatment method, there are still issues which need to be resolved to significantly improve this treatment (4). EVAR compared to open surgery repair is characterized by a reduced perioperative mortality, but the reintervention incidence after EVAR is still higher than after open surgery repair. Additionally, results of many studies indicate that the difference in mortality rate between EVAR and open surgery is reduced in a few years after the treatment (5). Successful endovascular treatment depends largely on the anatomical factors. The presence of an unfavorable anatomy like proximal aneurysmal neck length < 10 mm, diameter > 28 mm and angle > 60 degrees, conical shape, calcification or thrombus thickness > 2 mm covering > 180 degree of the circumference of the aorta belong to the adverse anatomical features. This challenging proximal aortic neck anatomy is called a “hostile neck”. This condition reduces the efficacy of endovascular treatment and predisposes to the stentgraft migration and/or increases the risk of type Ia endoleak development, blood inflow between the stentgraft and the aortic wall in the proximal landing zone (6, 7).

A variety of techniques are used in the treatment of AAA with a “hostile neck” anatomy. In order to adjust to the anatomical variability a suprarenal bare stents, stentgrafts with barbs and hooks, fenestrated stentgrafts, chimney graft technique or polymer-injected sealing rings have been deployed over the years (8, 9).

The idea of combining the advantages of minimally invasive endovascular procedure with the durability of an open surgery repair has led to the emergence of endovascular staples, also called endoanchors. The endoanchor objective is to tack the stentgraft through all three layers of the aortic wall. The aim is to provide the durability of the stentgraft fixation similar to that obtained with a sutured anastomosis during open surgery repair (10).

AAA was detected accidentally during the ultrasound examination of the 64 years old patient. Initially the aneurysm diameter was approximately 40 mm. Surveillance US examination performed after the 6 and 12 months revealed an aneurysm diameter increase to 50 mm. Another US examination performed because of the emergence of an abdominal pain, further expansion of the sac to 65 mm in diameter and tenderness during the pressure with a probe was observed.

Patient was sent to a vascular surgeon and an urgent CT angiography was performed. Due to the systematic enlargement of the AAA sac and the presence of abdominal pain during physical examination the patient was qualified for urgent stentgraft implantation.

CT angiography revealed a short aneurysmal neck and a thrombus placed on the right and anterior side of the aortic wall just below the renal arteries, comprising approximately 40% of the circumference of the abdominal aorta (fig. 1a, b). Moreover, the CT angiography presented a thrombus defect (“thrombus ulceration”) on the anterior wall of the AAA and an aneurysmal dilatation of the right common iliac artery proximal to the iliac bifurcation with a diameter of approximately 28 mm harbouring a small mural thrombus (fig. 1c). There were no obvious imaging features of the aneurysm rupture.