Endoscopic Aneurysm Sac Fenestration as a Treatment Option for Growing Aneurysms Due to Type II Endoleak or Endotension

Intraoperative Intrasac Thrombin Injection to Prevent Type II Endoleak after Endovascular Abdominal Aortic Aneurysm Repair

Purpose:

To report a prospective, nonrandomized pilot study to determine whether fibrin glue aneurysm sac embolization at the time of endovascular aneurysm repair (EVAR) is a safe and effective procedure to primarily prevent type II endoleaks.

Methods:

Between June 2003 and December 2005, 84 consecutive patients (79 men; mean age 73.8±7.8 years, range 64–86) with degenerative infrarenal abdominal aortic aneurysm underwent EVAR with bifurcated stent-grafts and fibrin glue injection into the aneurysm sac at the conclusion of the endovascular procedure. A total of 424 imaging studies and 348 visits were recorded during the study period and reviewed.

Results:

Selective catheterization of the aneurysm sac and fibrin glue injection immediately after initial stent-graft deployment was successful in 83 (99%) of 84 cases; there was one failure to access the excluded aneurysm sac due to severe iliac artery calcification. The estimated primary and assisted clinical success rates at 2 years were 91.3% and 98.8%, respectively, but the major findings were the low rate of delayed type II endoleak (2.4%) and the statistically significant decrease in the maximum transverse aneurysm diameter (50.40±6.70 versus 42.03±6.50 mm, p=0.0001) at follow-up. In addition, of 31 patients available for 24-month follow-up, 14 (45.2%) patients showed a reduction in maximum transverse aneurysm diameter by ≥5 mm; 16 (51.6%) patients had no significant changes, whereas only 1 patient showed a >5-mm enlargement.

Conclusion:

This clot engineering approach to aneurysm sac embolization at the time of endografting appears to be safe and may spare the patient a repeated catheter-based intervention or surgical procedure.

Possible Genetic Component to the Etiology of Perigraft Hygromas

Perigraft hygroma is a known complication of prosthetic graft implantation. The specific etiology of perigraft hygromas is still unknown. We report 2 brothers who underwent open abdominal aortic aneurysm repairs with polytetrafluoroethylene grafts that developed progressively enlarging perigraft hygromas. This is the first case report of 2 brothers developing sac hygromas after open abdominal aortic aneurysm repair. This case demonstrates that there could be a genetic component associated with the development of perigraft hygromas and further investigation of genetic etiologies should be considered.

Symptomatic aneurysm rupture without bleeding secondary to endotension 4 years after endovascular repair of an abdominal aortic aneurysm

PURPOSE

To demonstrate the absence of bleeding from a ruptured abdominal aortic aneurysm (AAA) without evidence of endoleak following endovascular aneurysm repair (EVAR).

CASE REPORT

A 72-year-old woman developed aneurysm enlargement 4 years after EVAR of an infrarenal AAA. During surgical exploration for abdominal pain and presumed aneurysm rupture, the ruptured aneurysm sac was found to be filled with gelatinous material without evidence of thrombus or active bleeding.

CONCLUSION

This case provides insight into the natural history of endotension and indicates that conservative management even in the face of an expanding aneurysm is a valid management option for selected patients.