Type 2 Endoleaks: Common and Hard to Eradicate yet Benign?

A Novel Combined Microsurgical and Endovascular Approach for Type II Endoleak Embolization Through Direct Puncture of a Lumbar Segmental Artery: A Technical Case Instruction

BACKGROUND AND IMPORTANCE

Despite the advances in endovascular aortic repair techniques, type II endoleaks with aneurysm sac expansion remain frequent and challenging problems.

CLINICAL PRESENTATION

An elderly gentleman underwent a combined microsurgical and endovascular procedure to address a type 2 endoleak and the growth of a recurrent abdominal aortic aneurysm caused by direct puncture of a lumbar segmental artery. The patient tolerated the procedure well and was discharged without complications. Follow-up imaging revealed no further endoleak and a smaller aneurysm size.

CONCLUSION

This unique case presents a novel multidisciplinary surgical strategy for treating complex, recurrent aortic aneurysms with type II endoleaks. The approach is tailored to the individual patient and has shown effectiveness. Long-term follow-up data will be crucial for assessing the efficacy and durability of this approach.

Circulating Extracellular Vesicles: Their Role in Patients with Abdominal Aortic Aneurysm (AAA) Undergoing EndoVascular Aortic Repair (EVAR)

Abdominal aortic aneurysm (AAA) is a frequent aortic disease. If the diameter of the aorta is larger than 5 cm, an open surgical repair (OSR) or an endovascular aortic repair (EVAR) are recommended. To prevent possible complications (i.e., endoleaks), EVAR-treated patients need to be monitored for 5 years following the intervention, using computed tomography angiography (CTA). However, this radiological method involves high radiation exposure in terms of CTA/year. In such a context, the study of peripheral-blood-circulating extracellular vesicles (pbcEVs) has great potential to identify biomarkers for EVAR complications. We analyzed several phenotypes of pbcEVs using polychromatic flow cytometry in 22 patients with AAA eligible for EVAR. From each enrolled patient, peripheral blood samples were collected at AAA diagnosis, and after 1, 6, and 12 months following EVAR implantation, i.e. during the diagnostic follow-up protocol. Patients developing an endoleak displayed a significant decrease in activated-platelet-derived EVs between the baseline condition and 6 months after EVAR intervention. Furthermore, we also observed, that 1 month after EVAR implantation, patients developing an endoleak showed higher concentrations of activated-endothelial-derived EVs than patients who did not develop one, suggesting their great potential as a noninvasive and specific biomarker for early identification of EVAR complications.

CT angiography for the assessment of EVAR complications: a pictorial review

Endovascular aneurysm repair (EVAR) is a minimally invasive treatment proposed as an alternative to open repair in patients with abdominal aortic aneurysms. EVAR consists in a stent-graft placement within the aorta in order to exclude the aneurysm from arterial circulation and reduce the risk of rupture. Knowledge of the various types of devices is mandatory because some stents/grafts are more frequently associated with complications. CT angiography is the gold standard diagnostic technique for preprocedural planning and postprocedural surveillance. EVAR needs long-term follow-up due to the high rate of complications. Complications can be divided in endograft device-related and systemic complications. The purpose of this article is to review the CT imaging findings of EVAR complications and the key features for the diagnosis.

Embolization of Type 2 Endoleaks in the Abdominal Aorta Using Ethylene Vinyl Alcohol Copolymer

BACKGROUND

 Type 2 endoleaks (T2EL) are the most frequent complication following endovascular aortic repair. Multiple studies primarily deal with the technical and clinical success of the embolization of persisting T2EL, thereby revealing controversial outcomes. Current reports rarely focus on the detailed execution of such a complex interventional procedure with respect to the difficult anatomic setting.

METHODS

 The present review provides an in-depth depiction and evaluation of the interventional methodology of the embolization of T2EL in the abdominal aorta with use of ethylene vinyl alcohol copolymer (EVOH). Complicating anatomic conditions are taken into account as well as technical and clinical success rates.

RESULTS

 Using the transarterial approach, there are at least 4 different pathways to access the nidus of a T2EL. CT-guided direct puncture of the aneurysm sac provides an alternative method of high technical success. EVOH with its slow solidification characteristics enables good control to achieve complete filling of the T2EL. During the intervention, however, it remains difficult to meet exactly the embolization endpoint, especially in large T2ELs.

CONCLUSION

 T2EL embolization using EVOH is an effective treatment with low major complication rates when conducted by skilled interventionists with detailed knowledge of diverse complex access routes.

KEY POINTS

  · Many roads lead to Rome to access the nidus of a T2EL including diverse complex transarterial pathways and direct aneurysm sac puncture.. · Ethylene vinyl alcohol co-polymer enables good control for slow filling of the nidus with low risk of major complications.. · Identification of the embolization endpoint remains difficult during the procedure and may result in secondary interventions.. · Successful T2EL embolization requires detailed knowledge of all access routes to the nidus and skilled handling of liquid embolics..

CITATION FORMAT

· Nolte-Ernsting C, Mecklenbeck F, Stehr A. Embolization of Type 2 Endoleaks in the Abdominal Aorta Using Ethylene Vinyl Alcohol Copolymer. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1502-7883.