Noninvasive Diagnosis of Incomplete Endovascular Aneurysm Repair: D-Dimer Assay to Detect Type I Endoleaks and Nonshrinking Aneurysms

Purpose: To test the hypothesis that D-dimer (D-D), a cross-linked fibrin degradation product of an ongoing thrombotic event, could be a marker for incomplete aneurysm exclusion after endovascular abdominal aortic aneurysm (AAA) repair. Methods: In a multicenter study, 83 venous blood samples were collected from 74 AAA endograft patients and controls. Twenty subjects who were >6 months postimplantation and had evidence of an endoleak and/or an unmodified or increasing AAA sac diameter formed the test group. Controls were 10 nondiseased subjects >65 years old, 18 AAA surgical candidates, and 26 postoperative endograft patients with no endoleak and a shrinking aneurysm. Blood samples were analyzed for D-D through a latex turbidimetric immunoassay. The endograft patients were stratified into 5 clinical groups for analysis: no endoleak and decreasing sac diameter, no endoleak and increasing/unchanged sac diameter, type II endoleak and decreasing sac diameter, type II endoleak and increasing/unchanged sac diameter, and type I endoleak. Results: Individual D-D values were highly variable, but differences among clinical groups were statistically significant (p < 0.0001). D-D values did not vary significantly between patients with stable, untreated AAAs and age-matched controls (238 ± 180 ng/mL versus 421 ± 400 ng/mL, p > 0.05). Median D-D values increased at 4 days postoperatively (963 ng/mL versus 382 ng/mL, p > 0.05) and did not vary thereafter if there was no endoleak and the aneurysm sac decreased. D-D mean values were higher in patients with type I endoleak (1931 ± 924 ng/mL, p < 0.005) and those with unchanged/increasing sac diameters (1272 ± 728 ng/mL) than in cases with decreasing diameters (median 638 ± 238 ng/mL) despite the presence of endoleak (p < 0.0005). Conclusions: Elevated D-D may prove to be a useful marker for fixation problems after endovascular AAA repair and may help rule out type I endoleak, thus excluding patients from unnecessary invasive tests.

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Modeling Endoleaks and Collateral Reperfusion following Endovascular AAA Exclusion

Journal of Endovascular Therapy ◽

10.1177/152660280301000305 ◽

2003 ◽

Vol 10 (3) ◽

pp. 424-432 ◽

Cited By ~ 10

Author(s):

Chuh K. Chong ◽

Thien V. How ◽

Geoffrey L. Gilling-Smith ◽

Peter L. Harris

Keyword(s):

Stent Graft ◽

Aortic Pressure ◽

Type I ◽

Type Ii ◽

Pump System ◽

Type Ii Endoleak ◽

Type I Endoleak ◽

The Impact ◽

Mean Aortic Pressure

Purpose: To investigate the effect on intrasac pressure of stent-graft deployment within a life-size silicone rubber model of an abdominal aortic aneurysm (AAA) maintained under physiological conditions of pressure and flow. Methods: A commercial bifurcated device with the polyester fabric preclotted with gelatin was deployed in the AAA model. A pump system generated physiological flow. Mean and pulse aortic and intrasac pressures were measured simultaneously using pressure transducers. To simulate a type I endoleak, plastic tubing was placed between the aortic wall and the stent-graft at the proximal anchoring site. Type II endoleak was simulated by means of side branches with set inflow and outflow pressures and perfusion rates. Type IV endoleak was replicated by removal of gelatin from the graft fabric. Results: With no endoleak, the coated graft reduced the mean and pulse sac pressures to negligible values. When a type I endoleak was present, mean sac pressure reached a value similar to mean aortic pressure. When net flow through the sac due to a type II endoleak was present, mean sac pressure was a function of the inlet pressure, while pulse pressure in the sac was dependent on both inlet and outlet pressures. As perfusion rates increased, both mean and pulse sac pressures decreased. When there was no outflow, mean sac pressure was similar to mean aortic pressure. In the presence of both type I and type II endoleaks, mean sac pressure reached mean aortic pressure when the net perfusion rate was low. Conclusions: In vitro studies are useful in gaining an understanding of the impact of different types of endoleaks, in isolation and in combination, on intrasac pressure after aortic stent-graft deployment.

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Sac Embolization and Side Branch Embolization for Preventing Type II Endoleaks After Endovascular Aneurysm Repair: A Meta-analysis

Journal of Endovascular Therapy ◽

10.1177/1526602819878411 ◽

2019 ◽

Vol 27 (1) ◽

pp. 109-116 ◽

Cited By ~ 4

Author(s):

Qiyi Li ◽

Peiyong Hou

Keyword(s):

Randomized Trials ◽

Meta Analysis ◽

Endovascular Aneurysm Repair ◽

Side Branch ◽

Type I ◽

Type Ii ◽

Related Complication ◽

Type Ii Endoleak ◽

Random Effects Models ◽

Aneurysm Repair

Purpose:To investigate the efficacy and safety of preoperative side branch embolization or intraoperative sac embolization for preventing type II endoleaks after endovascular aneurysm repair (EVAR). Materials and Methods: A systematic literature search of MEDLINE and EMBASE was performed to identify studies that evaluated the outcomes of sac embolization vs no embolization or side branch embolization vs no embolization in patients who received EVAR. Among the 904 studies screened, 17 studies with 2084 participants were included in this review. Outcome measures included the type II endoleak rate, the reintervention rate for type II endoleaks, the incidence of types I/III endoleaks, and the rate of complications. Fixed (no heterogeneity) or random effects models were constructed for each outcome; the results are presented as the odds ratio (OR) with 95% confidence interval (CI). Results: The sac embolization group had significantly lower type II endoleak (OR 0.21, 95% CI 0.13 to 0.34, p<0.001) and reintervention (OR 0.15, 95% CI 0.07 to 0.33, p<0.001) rates than the no embolization group. No significant differences between the 2 groups were found for the type I/III endoleak rate (OR 0.57, 95% CI 0.23 to 1.37, p=0.21) or complication rate (OR 1.22, 95% CI 0.32 to 4.70, p=0.77). Compared with no embolization, side branch embolization was also associated with a decrease in type II endoleak (OR 0.35, 95% CI 0.21 to 0.60, p<0.001) and reinterventions (OR 0.10, 95% CI 0.04 to 0.27, p<0.001). One severe procedure-related complication (fatal colon ischemia) was reported in the side branch embolization group. Conclusion: Sac embolization and side branch embolization are safe and effective in preventing type II endoleaks. Further randomized trials are needed to directly compare the clinical outcomes of these procedures.

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Distribution of Sac Pressure in an Experimental Aneurysm Model after Endovascular Repair: The Effect of Endoleak Types I and II

Journal of Endovascular Therapy ◽

10.1177/152660280301000317 ◽

2003 ◽

Vol 10 (3) ◽

pp. 516-523 ◽

Cited By ~ 9

Author(s):

Eleftherios S. Xenos ◽

Scott L. Stevens ◽

Michael B. Freeman ◽

John P. Pacanowski ◽

David C. Cassada ◽

...

Keyword(s):

Type I ◽

Type Ii ◽

Experimental Aneurysm ◽

Pump System ◽

Type Ii Endoleak ◽

Proximal Neck ◽

Aneurysm Wall ◽

Type I Endoleak ◽

Aneurysm Model ◽

P Distribution

Purpose: To study in an experimental aneurysm model the differential distribution of strain/pressure (S/P) on the aneurysm wall before and after endograft exclusion and in the presence of individual type I and type II endoleaks. Methods: Two tapered elliptical Gore-Tex patches were sutured to an anterior and posterior longitudinal arteriotomy of an 8-mm Gore-Tex tube graft, thus creating a fusiform aneurysm. Two S/P transducers were placed at the proximal sac adjacent to the proximal neck, 2 at the site of the widest sac diameter, and 2 at the sac adjacent to the distal neck. The aneurysm, which was connected to a pulsatile pump system, was excluded using a 10-mm endograft. Type I and type II endoleaks were created and tested individually. S/P measurements were obtained at systemic systolic pressures (BP) of 80, 110, and 150 mmHg. Thrombosis of the sac contents was induced by injection of thrombin and calcium in the sac. Angiography was used to verify presence or absence of flow in the sac. Results: Aneurysm exclusion resulted in significant S/P reductions at all 3 BP levels versus prior to exclusion (p<0.05). Thrombus in the sac did not alter S/P in the excluded sac (p>0.05 for all 3 BP levels). In the presence of a proximal type I endoleak, S/P distribution was not uniform, and S/P at the proximal neck was close to S/P prior to exclusion (p>0.05 no graft versus type I endoleak for all 3 BP levels). This was also true in the presence of thrombus. With a type II endoleak, S/P was more evenly distributed and was not significantly elevated compared to the pressure without an endoleak (p>0.05, graft versus type II endoleak for all 3 BP levels). Thrombus had no effect on intrasac S/P with a type II endoleak. Intrasac S/P was significantly higher in the presence of a type I endoleak compared to a type II endoleak when BP=150 mmHg (p=0.008). Conclusions: Endovascular exclusion of an aneurysm results in uniform S/P reduction in the aneurysm sac. Type I endoleak, but not type II endoleak, results in significantly higher S/P in an area of the sac adjacent to the proximal neck. Thrombus does not result in significantly different S/P distribution in the aneurysm sac.

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Image-guided translumbar type II endoleak repair: A novel approach

American Journal of Interventional Radiology ◽

10.25259/ajir_6_2019 ◽

2020 ◽

Vol 4 ◽

pp. 9

Author(s):

Salman Mirza ◽

Shahnawaz Ansari

Keyword(s):

Mesenteric Artery ◽

Inferior Mesenteric Artery ◽

Endovascular Aneurysm Repair ◽

Type Ii ◽

Type Ii Endoleak ◽

Image Guided ◽

Novel Approach ◽

Abdominal Aortic ◽

Aneurysm Repair

We present a case of a 72-year-old male with an abdominal aortic aneurysm status post-endovascular aneurysm repair (EVAR). Follow-up imaging demonstrated an enlarging type II endoleak and attempts at transarterial coil embolization of the inferior mesenteric artery were unsuccessful. The patient underwent image-guided percutaneous translumbar type II endoleak repair using XperGuide (Philips, Andover, MA USA).

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Faculty Opinions recommendation of Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718218160.793489012 ◽

2013 ◽

Author(s):

Norman Hertzer

Keyword(s):

Endovascular Aneurysm Repair ◽

Type Ii ◽

Type Ii Endoleak ◽

Aneurysm Repair

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Abdominal Aortic Disease: A Multicase Review

Journal for Vascular Ultrasound ◽

10.1177/1544316719829602 ◽

2019 ◽

Vol 43 (1) ◽

pp. 18-24

Author(s):

Joshua D. Lee ◽

Courtney Webb ◽

Mark W. Fugate

Keyword(s):

Patient Care ◽

Iliac Artery ◽

Endovascular Aneurysm Repair ◽

Artery Aneurysm ◽

Disease Diagnosis ◽

Aortic Disease ◽

Type I ◽

Abdominal Aortic ◽

Type I Endoleak ◽

Vascular Laboratory

Abdominal aortic disease affects more than 3 million people per year. For vascular sonographers, imaging aortic disease can become routine. Therefore, it is necessary to expand the knowledge that we have of aortic disease, diagnosis, and treatment. We present 4 cases with new or worsening conditions diagnosed by duplex ultrasound (DUS). Our first case is a 79-year-old woman returning for surveillance of an endovascular aneurysm repair (EVAR). The DUS findings reveal an increasing abdominal aortic aneurysm (AAA) sac, with evidence of flow originating from an incomplete seal at the attachment suggesting type I endoleak. Next, is a 56-year-old man returning 1 month after type A dissection repair, now presenting with unilateral claudication. The DUS findings of the left lower extremity demonstrated an early systolic deceleration waveform, suggesting more proximal disease. Upon further imaging, an abdominal aortic dissection was identified terminating into the left internal iliac artery, causing the true lumen to be compressed. The third case was a 75-year-old man returning for follow-up of an EVAR and iliac repair. The DUS findings show an increase in iliac artery sac size and anechoic area that was filled with color Doppler flow. These findings are suggestive of type I endoleak involving the distal attachment. The last case is a 56-year-old man returning for EVAR and iliac artery repair surveillance. The common iliac artery aneurysm sac had increased in diameter and length. The distal attachment of the left iliac extension cuff terminated within the aneurysm sac, causing a type I endoleak. Accurate DUS diagnosis of aortic disease is crucial for patient care. Meticulous analysis of the vessels and surrounding structures can make a difference in diagnostic outcomes. Vascular sonographers should continually review and revise vascular laboratory protocols to increase their diagnostic accuracy and improve patient care. It is important to extend the vascular laboratory protocols when complex cases arise to better demonstrate complicated diagnoses and challenging anatomy.

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