Natural history of gutter-related type Ia endoleaks after snorkel/chimney endovascular aneurysm repair

We report a case of a ruptured abdominal aortic aneurysm (AAA) caused by a combined type IIIb and Ia endoleak. Also, we propose the mechanism that resulted in this combined endoleak. Specifically, a 71-year old-man, with a previous history of endovascular aneurysm repair (EVAR) for an AAA, was diagnosed with a contained rupture. CT scan depicted a type Ia endoleak and a migrated Talent endograft. A proximal aortic cuff sealed the endoleak, but intraoperative angiography revealed that a type IIIb endoleak coexisted due to fabric tear close to the Talent bifurcation. A second aortic cuff could not seal the fabric tear; so, in-lay parallel limbs were sequentially deployed as a “kissing endograft” technique inside the cuff. Simultaneous treatment of combined type IIIb and Ia endoleaks has not yet been described. Maybe the type IIIb endoleak is the primary entity causing sac enlargement, neck recontouring, proximal migration, and ultimately type Ia endoleak, which leads to huge enlargement and rupture. Placement of an aortic cuff to seal the proximal endoleak/migration and kissing endografts limbs for the fabric tear seems a safe option in such patients.

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The natural history of type II endoleaks after endovascular aneurysm repair for ruptured abdominal aortic aneurysm

Journal of Vascular Surgery ◽

10.1016/j.jvs.2016.04.063 ◽

2016 ◽

Vol 64 (6) ◽

pp. 1645-1651 ◽

Cited By ~ 8

Author(s):

Anna E. Boniakowski ◽

Randall R. De Martino ◽

Dawn M. Coleman ◽

Jonathan L. Eliason ◽

Phillip P. Goodney ◽

...

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Natural History ◽

Endovascular Aneurysm Repair ◽

Type Ii ◽

Ruptured Abdominal Aortic Aneurysm ◽

Abdominal Aortic ◽

History Of ◽

Aneurysm Repair

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Natural History of Type II Endoleaks after Endovascular Aneurysm Repair in Abdominal Aortic Aneurysm

Vascular Specialist International ◽

10.5758/kjves.2011.27.4.162 ◽

2011 ◽

Vol 27 (4) ◽

pp. 162-167

Author(s):

Dong Min Cho ◽

Keun Myoung Park ◽

Shin Seok Yang ◽

Na Ri Kim ◽

Shin Young Woo ◽

...

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Natural History ◽

Endovascular Aneurysm Repair ◽

Type Ii ◽

Abdominal Aortic ◽

History Of ◽

Aneurysm Repair

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The natural history of type 2 endoleaks after endovascular aneurysm repair justifies conservative management

Vascular ◽

10.1177/1708538118766103 ◽

2018 ◽

Vol 26 (5) ◽

pp. 524-530 ◽

Cited By ~ 5

Author(s):

Mark Ajalat ◽

Russell Williams ◽

Samuel E Wilson

Keyword(s):

Natural History ◽

Conservative Management ◽

Endovascular Aneurysm Repair ◽

Spontaneous Resolution ◽

Type 2 Endoleak ◽

History Of ◽

Tomographic Angiography ◽

Aneurysm Repair

Objective Management of type 2 endoleaks after endovascular aneurysm repair has been controversial. Some advocate for conservative management, while others believe that intervention is indicated. This study investigated the natural history of type 2 endoleaks in order to derive direction in management. Methods Patients who had endovascular aneurysm repair at the Veterans Affairs Long Beach were retrospectively identified and computerized tomographic angiography was independently reviewed by a radiologist and a vascular surgeon. Type 2 endoleaks were analyzed for the following outcomes: rupture, duration of endoleak, spontaneous resolution, changes in the size of the aneurysm sac, and reintervention rates. Results Of the 160 patients who had completed required follow-up to date (mean 3 years) after endovascular aneurysm repair, 39 (24.4%) patients were identified as having a type 2 endoleak on computerized tomographic angiography imaging. 6 (15.4%) of these 39 patients required repair due to aneurysm sac growth >1 cm. 2 (5.13%) were repaired with an open procedure and 4 (10.3%) with an endovascular approach. Of these 6 aneurysm leaks requiring repair, 4 (66.7%) had a simultaneous endoleak (types 1 or 3) in addition to the identified type 2 endoleak. Spontaneous resolution of type 2 endoleaks occurred in 16 (41.0%) patients. 4 patients (10.3%) had delayed type 2 endoleaks that presented 4, 9, 12, and 23 months after their 30 day post op computed tomography was normal. None of the 4 patients with delayed type 2 endoleaks required reintervention and none had aneurysm sac growth greater than 5 mm. Conclusions Overall, we found that 85% of patients who had type 2 endoleaks did not require intervention after a mean follow-up time of 3 years. The association of a type 1 or 3 endoleak with a type 2 endoleak was more likely to require correction due to aneurysm expansion >1 cm, thus type 2 endoleaks associated with another type of endoleak require more aggressive management.

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Type 2 Endoleak Management

Seminars in Interventional Radiology ◽

10.1055/s-0040-1715873 ◽

2020 ◽

Vol 37 (04) ◽

pp. 365-370

Author(s):

James X. Chen ◽

S. William Stavropoulos

Keyword(s):

Natural History ◽

Endovascular Aneurysm Repair ◽

Treatment Strategies ◽

Current Treatment ◽

Type 2 Endoleak ◽

History Of ◽

Aneurysm Repair

AbstractType 2 endoleaks are the most common endoleak type following endovascular aneurysm repair. The natural history of these endoleaks can vary, with some demonstrating a self-limited or indolent course, while others can contribute to aneurysm sac enlargement and rupture. A variety of embolization techniques, including transarterial catheterization and direct sac puncture techniques, have been developed for the treatment of type 2 endoleaks. In this article, the authors review the indications, techniques, and outcomes of current treatment strategies for type 2 endoleaks.

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Comparing polymer-filled versus self-expanding endografts in Chinese patients

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492318810108 ◽

2018 ◽

Vol 26 (9) ◽

pp. 667-676

Author(s):

Yuk Law ◽

Yiu Che Chan ◽

Stephen Wing-Keung Cheng

Keyword(s):

Endovascular Aneurysm Repair ◽

Aortic Aneurysms ◽

The Self ◽

Chinese Patients ◽

Type Ii ◽

Mortality And Morbidity ◽

Type Ia ◽

One Year ◽

Aneurysm Repair

Introduction We performed a single-center nonrandomized study on patients who underwent endovascular aneurysm repair using polymer-filled or other self-expanding endografts. Methods Consecutive patients with asymptomatic infrarenal abdominal aortic aneurysms who underwent endovascular repair were retrospectively reviewed. They were divided into a polymer-filled ( n = 20) or self-expanding group ( n = 42). Baseline characteristics, operative mortality and morbidity, and follow-up data were compared. Results Aneurysm diameter, neck and iliac morphologies did not differ between the two groups. Technical success was 100%. The 30-day mortality was 0% and 2.4% in the polymer-filled and self-expanding group, respectively. At a mean follow-up of 17 months, the changes in sac size were −2.1 mm and −5.1 mm ( p = 0.144) at one year, and −3.5 mm and −7.7 mm ( p = 0.287) at 2 years in the polymer-filled and self-expanding group, respectively. The polymer-filled group had 7 (35%) type II endoleaks, and the self-expanding group had 1 (2.4%) type Ia and 13 (31%) type II endoleaks. Neck diameter remained stable in the polymer-filled stent-grafts whereas there was progressive neck degeneration in the self-expanding group. The rates of reintervention and overall survival were similar in both groups. The presence of an endoleak was the only predictor of non-regression of the aneurysm (odds ratio = 17.00, 95% confidence interval: 4.46–64.88, p < 0.001). Conclusion Polymer-filled endografts had similar safety, effectiveness, and durability to other self-expanding endografts. The major advantage is the small iliofemoral access. They also have the potential long-term benefit of a more stable neck.

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Endovascular Aneurysm Sealing (EVAS) and Chimney EVAS in the Treatment of Failed Endovascular Aneurysm Repairs

Journal of Endovascular Therapy ◽

10.1177/1526602816675622 ◽

2016 ◽

Vol 24 (1) ◽

pp. 115-120 ◽

Cited By ~ 23

Author(s):

Marwan Youssef ◽

Sebastian Zerwes ◽

Rudolf Jakob ◽

Oroa Salem ◽

Fritz Dünschede ◽

...

Keyword(s):

Endovascular Aneurysm Repair ◽

Multiple Organ ◽

Aortic Aneurysms ◽

Technical Success ◽

Graft Thrombosis ◽

Type Ia ◽

Aneurysm Repair ◽

Chimney Graft ◽

Bifurcated Graft

Purpose: To assess the technical success and clinical outcome of reinterventions using the Nellix Endovascular Aneurysm Sealing (EVAS) System to treat complications after endovascular aneurysm repair (EVAR). Methods: Fifteen consecutive patients (mean age 79 years; 14 men) with prior EVAR were treated with EVAS between March 2014 and December 2015 at 2 institutions. The failed prior EVARs included 13 bifurcated endografts, 1 bifurcated graft plus fenestrated cuff, and 1 tube endograft. Endoleaks were the predominant indications: type Ia in 10 and type III in 5 (3 type IIIa and 2 type IIIb). All patients presented with progressive aortic aneurysms (median 7.85-cm diameter; range 6.5–11). Eight patients were treated on an urgent or emergency basis (6 symptomatic aneurysms and 2 contained ruptures). All patients underwent Nellix relining of the failed stent-graft; 10 had chimney (Ch) procedures in combination with EVAS (chEVAS) because the proximal landing zones were inadequate. Results: Technical success was 100%. All endoleaks were successfully sealed, and no additional intervention was required. No further endoleak after EVAS or chEVAS was recorded. Endobag protrusion occurred in 1 case without sequelae. One elderly patient with ruptured aneurysm died from multiple organ failure 2 months postoperatively. One renal artery guidewire injury led to nephrectomy because of active bleeding. No reinterventions, aneurysm-related mortalities, graft thrombosis, endoleaks, or chimney graft occlusions were observed during a median follow-up of 8 months (range 3–24). Conclusion: The present preliminary experience demonstrates that the use of EVAS/chEVAS is feasible for treatment of failed EVAR. This technique may be used as bailout or an alternative treatment when other established methods are infeasible or not available.

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EndoAnchors Minimize Endoleaks in Chimney-Graft Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysms

Texas Heart Institute Journal ◽

10.14503/thij-17-6520 ◽

2019 ◽

Vol 46 (3) ◽

pp. 183-188 ◽

Cited By ~ 3

Author(s):

Edgar Luis Galiñanes ◽

Eduardo A. Hernandez-Vila ◽

Zvonimir Krajcer

Keyword(s):

Endovascular Aneurysm Repair ◽

Abdominal Aortic Aneurysms ◽

Aortic Aneurysms ◽

Graft Thrombosis ◽

Complex Anatomy ◽

Aortic Neck ◽

Abdominal Aortic ◽

Type Ia ◽

Aneurysm Repair ◽

Chimney Graft

Juxtarenal abdominal aortic aneurysms (AAAs) are difficult to treat because they often have little or no proximal aortic neck. Patients with this complex anatomy are not usually candidates for an endovascular aneurysm repair (EVAR). Chimney-graft EVAR has been introduced, but type Ia endoleak is a typical risk. We have begun using EndoAnchors to determine whether this risk can be reduced. From July 2013 through July 2014, we used the chimney-graft EVAR technique in 5 patients whose juxtarenal AAAs had a short or no proximal aortic neck. During the procedure, we implanted EndoAnchors as needed. Postprocedurally, at 30 days, and through end of follow-up (duration, 11–18 mo), all patients had patent endografts without type Ia endoleak (our primary endpoint), visceral stent-graft thrombosis, or renal complications. One patient who received 4 chimney grafts had a postprocedural type II endoleak, which was treated with embolization. We found it feasible to use EndoAnchors with the chimney-graft technique to prevent type Ia endoleaks in the treatment of juxtarenal AAAs. Further studies are needed to validate this adjunctive technique and to determine its durability.

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Type II Endoleak after Endovascular Aneurysm Repair: Natural History and Treatment Outcomes

Annals of Vascular Surgery ◽

10.1016/j.avsg.2017.04.029 ◽

2017 ◽

Vol 44 ◽

pp. 94-102 ◽

Cited By ~ 12

Author(s):

Liana Kumar ◽

Prue Cowled ◽

Margaret Boult ◽

Stuart Howell ◽

Robert Fitridge

Keyword(s):

Natural History ◽

Treatment Outcomes ◽

Endovascular Aneurysm Repair ◽

Type Ii ◽

Type Ii Endoleak ◽

Aneurysm Repair

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Determination of Endograft Apposition, Position, and Expansion in the Aortic Neck Predicts Type Ia Endoleak and Migration After Endovascular Aneurysm Repair

Journal of Endovascular Therapy ◽

10.1177/1526602818764616 ◽

2018 ◽

Vol 25 (3) ◽

pp. 366-375 ◽

Cited By ~ 13

Author(s):

Richte C. L. Schuurmann ◽

Kim van Noort ◽

Simon P. Overeem ◽

Ruben van Veen ◽

Kenneth Ouriel ◽

...

Keyword(s):

Endovascular Aneurysm Repair ◽

Renal Arteries ◽

Added Value ◽

Control Group ◽

Main Body ◽

Aortic Neck ◽

Type Ia ◽

And Migration ◽

Aneurysm Repair

Purpose: To describe the added value of determining changes in position and apposition on computed tomography angiography (CTA) after endovascular aneurysm repair (EVAR) to detect early caudal displacement of the device and to prevent type Ia endoleak. Methods: Four groups of elective EVAR patients were selected from a dataset purposely enriched with type Ia endoleak and migration (>10 mm) cases. The groups included cases of late type Ia endoleak (n=36), migration (n=9), a type II endoleak (n=16), and controls without post-EVAR complications (n=37). Apposition of the endograft fabric with the aortic neck, shortest distance between the fabric and the renal arteries, expansion of the main body (or dilatation of the aorta in the infrarenal sealing zone), and tilt of the endograft toward the aortic axis were determined on the first postoperative and the last available CTA scan without type Ia endoleak or migration. Differences in these endograft dimensions were compared between the first vs last scan and among the 4 groups. Results: No significant differences in endograft configurations were observed among the groups on the first postoperative CTA scan. On the last CTA scan before a complication arose, the position of the fabric relative to the renal arteries, expansion of the main body, and apposition of the fabric with the aortic neck were significantly different between the type Ia endoleak (median follow-up 15 months) and migration groups (median follow-up 23 months) compared with the control group (median follow-up 19 months). Most endograft dimensions had changed significantly compared with the first postoperative CTA scan for all groups. Apposition had increased in the control group but had decreased significantly in the type Ia endoleak and migration groups. Conclusion: Progressive changes in dimensions of the endograft within the infrarenal neck could be detected on regular CTA scans before the complication became urgent in many patients.

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