Endovascular Repair of Type IIIb Endoleak With the Amplatzer Septal Occluder

[Endoleaks in endovacular infrarenal abdominal aortic aneurysm repair. (Part II)]

Searching for literature data was performed in the PubMed, Scopus and eLIBRARY databases. In the second part, we considered modern classifications of endoleaks type 3, 4 and 5 after endovascular infrarenal abdominal aortic aneurysm repair, etiology, risk factors, classification of endoleaks. Modern data on effectiveness of their treatment by various methods are presented.

Type IIIb Endoleak After Endovascular Aneurysm Repair Using the Zenith Stent Graft

We present 3 cases of type IIIb endoleak after endovascular aneurysm repair (EVAR) using the Zenith stent graft system. Type III endoleak, like type I endoleak, is a high-pressure, high-risk leak that increases sac pressure up to or even above arterial pressure, and is associated with an increased frequency of open conversions or risk of aneurysm rupture. Type IIIb endoleak is rare but there is much concern that the incidence of type IIIb endoleak is likely to increase hereafter; the mechanism of type IIIb endoleak is deterioration of graft fabric in conjunction with stent sutures. Type IIIb endoleak is difficult to diagnose before rupture. The possibility of type IIIb endoleak should be highly suspected when the continued growth of an excluded aneurysm sac without direct radiologic evidence is observed during follow-up. Type IIIb endoleak can be repaired by relining of the stent graft with additional stent grafts.

Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review

INTRODUCTION

The aim of this article is to investigate the presentation, etiology, management and outcomes of type IIIb endoleak after endovascular aneurysm repair (EVAR).

EVIDENCE ACQUISITION

Electronic bibliographic databases were searched to identify published reports of type IIIb endoleak after EVAR, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards.

EVIDENCE SYNTHESIS

In total 33 articles were identified reporting on a total of 50 patients spanning 19 years of EVAR (1998-2017). Some 11 device-types were used. The median time from implantation to intervention was 27 months (0-168). There was a significant aneurysm sac expansion in 69% of reported cases. Thirteen patients (26%) presented with aneurysm rupture. A definitive diagnosis of type IIIb endoleak made on computed tomographic angiography (CTA) in only 20% of cases. Proposed failure modes included suture breakage, graft erosion by stents, iatrogenic, graft infection and presumed manufacturing faults. Endoleak location was in the main body in 81% of reported cases. Almost one third (31%) of patients were treated with open repair. The remaining patients were treated with endovascular techniques or hybrid procedures. Some novel off-label endovascular solutions were proposed to maintain a bifurcated configuration. Thirty-day mortality in patients treated for aneurysm rupture was 50%. The 30-day mortality rate in non- rupture cases was 2% (endovascular 0% treatment, open 2%).

CONCLUSIONS

Type IIIb endoleak is a serious condition associated with a significant risk of rupture. Definitive diagnosis is challenging and has been described in almost all conventional devices. Most patients can be treated successfully by endovascular means, though maintaining a bifurcated configuration may require non-standard techniques or off-label use.