Strategies of endoleak management following endoluminal treatment of abdominal aortic aneurysms in 95 patients: how, when and why

Diagnosis of Type IV Endoleak After Endovascular Aneurysm Repair Using Visualization With Novel Software

A Type IV endoleak is a very rare complication following endovascular aneurysm repair (EVAR) and differential diagnosis can be difficult. Reported here is a case that showed the development of a Type IV endoleak after an EVAR procedure, for which a novel software was useful to differentiate that from Type I based on visual confirmation. The 89-year-old man was diagnosed with a large abdominal aortic aneurysm, sized 70 mm, as shown by computed tomography (CT). EVAR was performed in a routine fashion using an Endurant II stent graft. Postoperative CT revealed a massive endoleak around the neck that was difficult to differentiate between Types I and IV. The use of the novel software Viewtify (SCIEMENT, Inc., Tokyo, Japan) to visualize the endoleak with surrounding tissues as real-time three-dimensional computer graphics (3DCG) resulted in confirmation that the endoleak was not from the proximal end but rather the stent graft body. CT findings obtained one week later showed that the endoleak had diminished and no additional procedures were needed. Following a diagnosis of endoleak after EVAR, images viewed with Viewtify helped to confirm the appropriate diagnosis. This novel software was found useful to clarify the position and mechanism of a Type IV endoleak.

Endovascular treatment of arteriovenous fistula caused by ruptured iliac aneurysm and type II endoleak

Arteriovenous fistulas (AVFs) caused by an isolated iliac aneurysm rupture and postoperative type II endoleak are rare and life threatening. We report here a case of AVF caused by a ruptured iliac aneurysm and postoperative type II endoleak. The patient was successfully treated by implanting a covered stent to treat the ruptured iliac aneurysm. However, type II endoleak with AVF persisted after the operation and was treated with transiliac vein embolization. The patient recovered uneventfully during the 2-month follow-up period.

Comparison of portable ultrasound system and high end ultrasound system in detection of endoleaks

PURPOSE

To compare the value of a portable ultrasound system and a high end ultrasound system in detection of endoleaks after EVAR.

MATERIAL AND METHODS

In this retrospective study, a cohort of 25 patients underwent both standard examination using a portable ultrasound system (Philips VISIQ) and a second examination using a high end ultrasound system (Philips EPIQ 7). The examination included B-mode and color Doppler in detection of endoleaks. Additional the maximum diameter of the aneurysm was measured in two planes (right-left and ventral-dorsal). The gold standard was contrast-enhanced ultrasound (CEUS) in detection of endoleaks.

RESULTS

25 patients were included in the study. Patients were predominantly male (n = 23) with an average age of 73,30±7.82 years (range 54-85). Diameters of the treated aneurysms were in the right-left plane 5,32±1.88 cm and ventral-dorsal 4,99±1.78 cm using the high end system. Diameters of the treated aneurysms were in the right-left plane 5,30±1.82 cm and ventral-dorsal 4,87±1.74 cm using portable ultrasound system. In 80% of the cases CEUS could detect an endoleak. Whereas the high end system could detect in B-mode 40% and color Doppler 45% of the cases an endoleak. The portable system could detect in B-mode 30% and in color Doppler 35% of the cases an endoleak. On both systems in B-mode a false positive endoleak was found on the same patient. All high flow endoleaks, which needed intervention, could be detected on all systems.

CONCLUSION

The high end ultrasound system does not seem to have an additional advantage in the measurement of the aneurysm diameter. Due to a higher resolution, more endoleaks could be detected in B-mode and color Doppler by using the high end system. The presence of small endoleaks could only be detected by using contrast enhanced ultrasound on an high end ultrasound system. High flow endoleaks could be reliable seen on both systems.

Fenestrated and Branched Stent Grafting in Complex Aneurysmatic Aortic Disease: A Single-Center Early Experience

BACKGROUND

The aim of this study is to present our early experience and highlight the technical difficulties associated with the use of fenestrated and branched stent grafts to treat patients with juxtarenal abdominal aortic aneurysm (AAA), pararenal AAA, and thoracoabdominal aortic aneurysms (TAAAs).

METHODS

A prospectively held database maintained at our department was queried for patients who have undergone branched and fenestrated stent grafting for AAA or TAAA treatment. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality, morbidity, and reintervention rate were evaluated.

RESULTS

A total of 8 patients underwent repair with a fenestrated or branched stent graft. All patients had aneurysmal degeneration of the juxtarenal aorta, pararenal aorta, and thoracoabdominal aorta not suitable to standard endovascular techniques. Two patients had a prior aortic repair, a failed migrated stent graft, and an old surgical tube graft after an open repair. One patient had a type III TAAA and 1 patient had a postdissection TAAA type I. For all patients, target vessel success rate was 96.4% (27/28) and mean hospital stay was 6.0 days (range 3-21). Thirty-day and 1-year mortality were 0%. Mean follow-up was 23 months (range 7-45). Two endoleaks occurred, 1 type III and 1 type II, which were treated endovascularly. No death or major complication occurred during follow-up.

CONCLUSIONS

Fenestrated and branched endovascular stent grafts can be used to repair juxtarenal AAA, pararenal AAA, and TAAA in patients with significant comorbidities. However, several technical challenges have to be overcome due to the unique complex aortic pathology of each patient.

Aortic rupture following an EVAR secondary to graft erosion

Significant type 3 endoleak as a defect in the graft material, especially associated with endograft rupture, is a rare complication. A 68-year-old male patient with aortic plaque rupture was treated with endovascular graft placement. The patient was readmitted two years later with severe abdominal pain, a large retroperitoneal hematoma and contrast extravasation below the location where the aortic plaque had presented. Before an aortic infrarenal cuff could be placed during a control angiography, a large graft hole and a significant type 3 endoleak were observed. The sharp aortic plaque may have been responsible for the endograft tear.

Diagnosis and treatment of a patient with type IV endoleak as a late complication after endovascular aneurysm repair

Type IV endoleak is a very rare complication observed after implantation of aortobiiliac stent grafts. The difficult diagnosis of type IV endoleak leads to the application of many imaging methods in the diagnostic process. We present a case report of a patient who underwent implantation of an aortobiiliac stent graft in 2004. After surgery, the size of the aneurysm sac was monitored continually in the subsequent imaging studies. Progression of the aneurysm sac volume was detected in 2009. In a short period of time, the diameter of the aneurysm increased from 100 to 140 mm. Angio-computed tomography and angiography did not reveal the location of the endoleak. The attempt at localization and endovascular closure of the source of the endoleak failed. It was decided to treat the patient surgically. Intraoperatively, the source of the endoleak was visualized, and the endoleak was closed with surgical sutures.

Type 2 Endoleaks Post-EVAR: Current Evidence for Rupture Risk, Intervention and Outcomes of Treatment

Type 2 endoleaks (EL2) are the most commonly encountered endoleaks following EVAR. Despite two decades of experience, there remains considerable variation in the management of EL2 with controversies ranging from if to treat, when to treat and how to treat. Here, we summarise the available evidence, describe the treatment techniques available and offer guidelines for management.

Quality improvement guidelines for imaging detection and treatment of endoleaks following endovascular aneurysm repair (EVAR)

Major concerns after aortic aneurysm repair are caused by the presence of endoleaks, which are defined as persistent perigraft flow within the aortic aneurysm sac. Diagnosis of endoleaks can be performed with various imaging modalities, and indications for treatment are based on further subclassifications. Early detection and correct classification of endoleaks are crucial for planning patient management. The vast majority of endoleaks can be treated successfully by interventional means. Guidelines for Imaging Detection and Treatment of endoleaks are described in this article.

Aortic-neck dilation after endovascular abdominal aortic aneurysm repair (EVAR): can it be predicted?

PURPOSE

This study was performed to evaluate whether dynamic computed tomography (CT) can provide functional vessel information predicting outcomes of aortic neck in patients undergoing endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm (AAA).

MATERIALS AND METHODS

Twenty patients with and 20 without AAA were enrolled. Electrocardiographically (ECG)-gated data sets were acquired with a 64-slice CT scanner. Axial pulsatility measurements were taken at three levels: 2 cm above the highest renal artery; immediately below the lowest renal artery; 1 cm below the lowest renal artery. Three independent readers performed the measurements. Systolic and diastolic blood pressures were measured in the brachial artery to calculate arterial-wall distensibility expressed as pressure strain elastic modulus (Ep). Cross-sectional area change, wall distensibility and Ep value were statistically compared.

RESULTS

No significant differences were found in terms of Ep values in the suprarenal and juxtarenal level. In the AAA group, a significantly higher value was obtained at the infrarenal level. A subgroup of patients with AAA (45%) had a significantly higher Ep value at the infrarenal level.

CONCLUSIONS

Dynamic CT provided insight into the abdominal aorta pathophysiology. Identifying patients with higher infrarenal distensibility could change selection of graft size to improve proximal fixation.