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References
277
References
1. DeVries JPPM, Ouriel K, Mehta M, Varnagy D,
et al. Analysis of EndoAnchors for endovascular
aneurysm repair by indications for use. J Vasc Surg.
2014;66:1460–7.
2. Arko FR, Stanly GA, Pearce BJ, Henretta JP. Endo
suture aneurysm repair in patients treated with
Endurant II/IIS in conjunction with Heli-FX
EndoAnchor implants for short neck. J Vasc Surg.
2019;70:732–40.
3. Varkevisser RRB, O’Donnell TF, Swerdlow NJ, Liang
P, et al. Fenestrated endovascular aneurysm repair is
associated with lower peri-operative morbidity and
mortality compared with open repair of complex
AAAs. J Vasc Surg. 2019;69(6):1670–8.
Endovascular Aneurysm Repair
Followed by Multiple
Interventions forEndoleaks
63
History andProcedures
A 78-year-old male underwent endovascular
aneurysm repair (EVAR) with AneuRx graft for
an enlarging 5.2 cm (transverse/AP diameter)
abdominal aortic aneurysm (AAA) in April 2007.
In 2006, the AAA measured 4.4cm in transverse
diameter. The main body of the AneuRx graft
(Medtronic, Dublin Ireland) was deployed from
the right femoral artery (28×16×135mm), contralateral iliac limb 18×18×115mm, and ipsilateral iliac extension limb 18 × 18 × 55 mm.
Completion aortogram showed satisfactory lling of both renal arteries and hypogastric arteries.
Patient was followed by CTA of the abdomen and
pelvis and duplex ultrasound studies, and the
aneurysm sac remained stable on a 6-month basis
(alternate CTA with ultrasound). CTA of the
abdomen and pelvis in August 2010 showed Type
II endoleak (Fig.63.1).
During postoperative follow-up, aneurysm sac
remained stable with no evidence of endoleak
until August 2010, aneurysm sac increased in
size to 5.6×5.6cm, and there was increasing size
of endoleak 2.8×1.3cm most probably from the
iliolumbar artery on the left side. Therefore, in
September 2010, patient underwent coil embolization of the iliolumbar artery by placing an
Omniush catheter in the right common iliac
artery and selecting the hypogastric artery. We
used a 25-cm-long 5 F sheath to engage the
Kumpe catheter and the glidewire into the hypo-
gastric artery. Using glidewire we were able to
selectively engage the iliolumbar artery, and contrast injection showed the site of endoleak. Two
MReye® 3 × 2 Embolization Coils (Cook
Medical, Bloomington, IN, USA) were placed
followed by three Nester® Embolization Coils
(Cook Medical) 4×14mm (Fig.63.2). A follow up completion arteriogram showed successful
embolization of the iliolumbar artery. The aneurysm sac remained stable for 6-month ultrasound
performed four times. In July 2012, the aneurysm
sac measured 5.6cm×5cm with demonstration
of Type II endoleak (no change in the size of
aneurysm sac).
Fig. 63.1 CT scan showing Type II endoleak
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_63
279
280
Fig. 63.2 Coil embolization of iliolumbar artery following access to hypogastric artery in 2012. Please note the coils
on the right side following embolization of the iliolumbar artery 2010
63 Endovascular Aneurysm Repair Followed by Multiple Interventions forEndoleaks
In March 2015, aneurysm sac enlarged to
6cm ×5.8 cm, and patient underwent superior
mesenteric artery arteriogram and bilateral hypogastric arteriogram. No other source of endoleak
was identied except from the iliolumbar artery
on the left side. The right hypogastric artery
injection did not show any evidence of endoleak.
Following a puncture of the left femoral artery,
RIM catheter was placed in the hypogastric artery
and the iliolumbar artery was then engaged.
Using a PROGREAT® catheter (Terumo
Interventional Systems, Somerset, NJ, USA)
with a micro 0.018 wire, the catheter was
advanced to the site of the endoleak. Subsequently,
three 3 mm x 14 cm long microcoils were
deployed with a micropusher. Completion run
showed satisfactory embolization with absent
lling of the iliolumbar artery.
Follow-up CTA examination of the abdomen
and pelvis showed satisfactory result with no evidence of Type II endoleak. In March 2018, CTA
of the abdomen and pelvis showed aneurysm sac
of 6.3 × 6.1 cm with no denitive evidence of
endoleak. There was migration of the AneuRx
graft distal to the renal arteries; the distance from
the superior end of the graft increased to 1.5cm
from the lowest renal artery. Patient underwent a
follow- up CTA of the abdomen and pelvis on
September 2018, the aneurysm sac further
enlarged to 6.7 × 6.3 cm, and now a Type IA
endoleak became obvious. Patient underwent
repair of Type IA endoleak by placing an
Endurant aortic extension cuff (32×32×49mm)
with balloon angioplasty with Reliant™ Stent
Graft Balloon (Medtronic) of the aortic cuff.
Completion run showed resolution of the Type IA
endoleak (Fig.63.3). Patient had been followed
by duplex ultrasound of the abdominal aorta in
June 2019, and the last two measurements of the
aneurysm sac have remained stable (6.7×6.3cm)
with no demonstration of endoleak (September
2019).
Discussion
The management of endoleak following EVAR
continues to present dilemmas for vascular surgeons. There is uniform consensus regarding the
merit of prompt treatment of Type I and III
endoleaks. The natural history of Type II endoleaks remains a matter of considerable debate.
Recent studies have demonstrated that nearly
20% of early Type II endoleaks persist, and that
persistent Type II endoleaks are associated with
secondary interventions, sac enlargement, and
rupture of the AAA [1–4].
Type I endoleaks result from failure of the
stent graft to achieve a circumferential seal at the
proximal (IA) or distal (IB) attachment sites.
This results in pressurization of the sac at the systemic blood pressure level with risk of rupture.
With advances in EVAR technology and increasing experience of the interventionalists, patients
Discussion
Fig. 63.3 Showing aortic cuff placement for Type IA endoleak secondary to migration of the graft (2018)
281
with hostile neck anatomy (short, angulated,
reversed tapered neck, circumferential thrombus,
or calcication) which required open AAA repair
in the past can now be treated with endovascular
means albeit with increased risk of Type IA
endoleak. Completion arteriography following
EVAR and cone beam computed tomography has
improved sensitivity for intraoperative detection
of Type IA endoleaks. Late Type IA endoleaks
result from endograft failure at the proximal seal
zone or migration especially in patients with hostile aortic neck anatomy. Zhou etal. evaluated
213 consecutive patients retrospectively who
underwent EVAR at a referral Veterans
Administration medical center, and they excluded
patients with less than 1 year follow-up [4]. Their
analysis included 183 patients, with a mean follow-up of 53months (range 12–141months); of
these 48 patients (26%) had endoleaks and 31
(17%) had aneurysm sac progression. The mean
diagnosis time for non-Type II (n=14) endoleak
was 45 months, and 71% were diagnosed less
than 1 year after EVAR. An isolated Type II
endoleak was detected in 34 patients at an average of 14.4 months (range 0–76 months) after
EVAR, 41% of which were detected less than 1
year after EVAR. They observed that 59% of
patients with a Type II endoleak had a signicant
enlargement of aneurysm sac. Delayed Type II
endoleaks were signicantly associated with sac
enlargement as compared to early Type II endoleaks [4].
The effectiveness of intervention for Type II
endoleaks is debatable. Sarac etal. reported satisfactory early results with coil embolization for
early Type II endoleaks [2]. They performed 140
embolization procedures in 95 patients (2000–
2008). A signicant number of patients required
multiple interventions with eight patients requiring explantation of the graft. Aziz etal. observed
that percutaneous intervention for Type II
endoleak did not appear after the rate of aneurysm
sac growth and most of their patients had persistent or recurrent endoleaks [3]. Jones et al.
detected 164 patients with Type II endoleaks [1].
Out of 1873 patients who underwent EVAR
between 1994–2005 131 (79.9%) developed early
Type II endoleaks with complete resolution at less
than 6 months. Persistent Type II endoleaks
occurred in 33 patients with persistent Type II
endoleaks with aneurysm rupture in four patients.
Transarterial coil embolization and direct sac
embolization are two techniques for patients with
lumbar artery-related Type II endoleaks, and the
latter is preferred by most investigators. Agents
such as Onyx® glue (ev3, Inc., Bovine, CA, USA)
282
63 Endovascular Aneurysm Repair Followed by Multiple Interventions forEndoleaks
or liquid embolic material (n-butyl cyanoacrylate
monomer) are agents used for embolization.
Recently, Madigan et al. reported that most
Type II endoleaks have a benign natural history,
but 6–8% are associated with sac enlargement
[5]. They reported 130 patients with Type II
endoleak, with a median time of 6.9±3.5years
(mean 2.3±1.1years); 118 had initial treatment
for primary Type II endoleak; of 118 treated for
Type II endoleak, 26 (22%) required treatment
for delayed Type I endoleak and Type III
endoleak. Those patients with delayed Type I and
III endoleaks had a lower successful treatment
rate than those with isolated Type II endoleaks.
They concluded that failed attempt at treating
Type II endoleaks for rapid sac growth rate (5mm
a year or greater) should raise the suspicion of a
delayed Type I or III endoleak [5].
The patient in this report had two interventions for Type II endoleak; 9 years after index
procedure (EVAR), he required correction of
Type IA endoleak in 2018. It is possible that Type
IA endoleak was not detected earlier, and after
treatment of Type II endoleaks, Type I endoleak
became obvious. In this patient, an important
cause of Type IA endoleak was migration of the
rst-generation endograft (AneuRx) which lack
proximal xation. This case illustrated the need
for continuous surveillance of endografts with
imaging studies (CTA of the abdomen and/or
duplex ultrasound of the abdomen).
References
1. Jones JE, Atkins MD, Brewster DC, Chung TK,
et al. Persistent type II endoleak after endovascular
repair of an abdominal aortic aneurysm that is associated with adverse late outcomes. J Vasc Surg. 2007;
46(1):1–8.
2. Sarac TP, Gibbons C, Vargis L, Liu J, et al. Longterm follow up of type II endoleak embolization
revealed the need for close surveillance. J Vasc Surg.
2012;55:33–40.
3. Aziz A, Menies CO, Sanchez LA, Picus D.Outcomes
of percutaneous endovascular intervention for type
II endoleak with aneurysm expansion. J Vasc Surg.
2012;55:1263–7.
4. Zhou W, Blay E Jr, Varu V, Ali S, et al. Outcome
and clinical signicance of delayed endoleaks after
EVAR.J Vasc Surg. 2014;59:915–20.
5. Madigan MC, Singh MJ, Cherr MA, El-Khoury
GE.Occult type I or III endoleaks are a common cause
of failure of type II endoleak after EVAR.J Vasc Surg.
2019;69:432–9.
Aortic Neck Rupture During
Endovascular Aneurysm Repair
inaPatient withaHorseshoe
Kidney
64
History andProcedures
A 75-year-old female was found to have 6.0cm
infrarenal abdominal aortic aneurysm (AAA)
with a horseshoe kidney (Fig. 64.1). Medical
comorbidities included hypertension and obesity (BMI 42). She underwent endovascular
aneurysm repair (EVAR) on October 21, 2010,
under spinal anesthesia with AneuRx graft
(Medtronic, Dublin Ireland). Main body of the
stent graft was deployed from the right side
(26×15×135mm) as well as right iliac extension limb (15× 15 × 85mm) and contralateral
iliac limb (15 × 15 × 115 mm). Following
Reliant™ (Medtronic) balloon angioplasty of
the aortic neck, patient became hypotensive
(systolic blood pressure 80 mmHg), and contrast injection through the 16F sheath showed
extravasation of the contrast at the aortic neck
(Fig.64.2). Immediately the aortic balloon was
inated in the suprarenal segment of the aorta,
and 26×26× 40 mm AneuRx aortic cuff was
placed close to the opening of the left renal
artery which was lower than the right renal
artery. Postoperative CTA scan of the abdomen
and pelvis (second postoperative day) showed
Fig. 64.1 Abdominal aortogram showing suprarenal AAA with horseshoe kidney
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_64
283
284
Fig. 64.2 Extravasation of contrast near the aortic neck
Fig. 64.3 Postoperative CTA showing successful man-
agement of aortic neck rupture and exclusion of AAA
64 Aortic Neck Rupture During Endovascular Aneurysm Repair inaPatient withaHorseshoe Kidney
satisfactory exclusion of the aneurysm without
endoleak (Fig.64.3). The hematoma surrounding the aortic neck was small in size. Patient
underwent follow-up imaging with CTA of the
abdomen and duplex ultrasound of the abdomen
every 6 months (alternating CTA with duplex
ultrasound) which showed continuous shrinkage
of the aneurysm sac, and on CTA performed in
July 2012, aneurysm sac measured 3.5×3.8cm.
Patient underwent CTA of the abdomen and pelvis in July 2018 which showed aneurysm sac
Fig. 64.4 Type IA endoleak
enlargement (5.3 × 5.9 cm) with Type II
endoleak from the renal artery supplying the
isthmus of the horseshoe kidney. There was also
a strong suspicion of a Type IA endoleak
(Fig. 64.4). Patient was taken to the operating
room in August 2018; via right femoral artery
and a left brachial approach, coil embolization
of the proximal false aneurysm sac was performed (Fig. 64.5). An iCAST™ (Atrium,
Charlotte NC) 6×38mm stent with Endurant™
(Medtronic) cuff 32×32×49mm was deployed
at the same time (snorkel technique). The wire
was passed into the left renal artery via brachial
artery approach, and the Endurant cuff was
deployed through the femoral approach.
Completion arteriogram showed resolution of
Type IA endoleak (Fig. 64.6). Follow-up CTA
scan in September 2018 showed stable aneurysm
sac (5.9×5.3cm) with persistent Type II endoleak
from arterial branch of the isthmus of the kidney.
In March 2019, aneurysm sac enlarged to
6.2×5.8cm, and 6 months later (September 2019)
the aneurysm sac measured 6.2 × 5.8 cm with
probable Type II endoleak arising from either inferior mesenteric artery or accessory renal artery
arising from the isthmus of the kidney (Fig.64.7).
Patient underwent abdominal aortogram,
superior mesenteric arteriogram, and bilateral
hypogastric arteriogram in January, 2020. There
was no evidence of Type I, II, or III endoleak.
History andProcedures
Fig. 64.5 Intraoperative aortogram following coil embolization of proximal false aneurysm sac and placement of
iCAST stent in left renal artery
285
Fig. 64.6 Postoperative CTA showing successful resolution of Type IA endoleak
Fig. 64.7 CTA of the abdomen and pelvis (September 2019) probable Type II endoleak with iCAST stent in the left
renal artery
286
64 Aortic Neck Rupture During Endovascular Aneurysm Repair inaPatient withaHorseshoe Kidney
Therefore patient will undergo follow-up CTA
abdomen and pelvis in 6months.
Discussion
Iliac rupture, due to its small caliber, calcication, and tortuosity during EVAR and TEVAR,
has been previously reported. Aortic rupture during EVAR is relatively uncommon. In this patient,
overzealous ination of the Reliant balloon at the
aortic neck may have contributed to aortic rupture. Aortic/iliac rupture during EVAR should be
immediately managed by proximal aortic balloon
ination and placement of a covered stent at the
site of rupture [1, 2].
The appearance of Type IA endoleak 8 years
later is related to a probable increase in the aortic
neck diameter and lack of proximal xation in
rst-generation grafts (AneuRx). Proximal zone
failures may be associated with a placement of
aortic extender cuff at the time of index operation
as was present in this patient. Aneurysm sac has
shown small enlargement even after correction of
Type IA endoleak, and if this trend persists,
embolization of the aneurysm sac preferably by
translumbar approach will be considered. In this
patient, because of 2mm aortic neck, fenestrated
graft was not considered as an option, and a snorkel technique with iCAST stent in the left renal
artery was preferred. Snorkel/chimney techniques have been developed to address the lack of
widespread availability and manufacturing limitations with branched/fenestrated devices for the
treatment of AAA with challenging aortic neck
anatomy and associated signicant medical
comorbidities. Ullrey etal. reported 60 patients
who underwent ch. EVAR with a total of 111
snorkel stents (97 renal, 12 superior mesenteric
artery, and 2 celiac) and observed that early
gutter- related Type I endoleaks were noted in
30% [1]. Follow-up imaging revealed spontaneous resolution of these gutter endoleaks in 88.4%
of patients at 18 months. Relatively few ch.
EVAR patients require reintervention related to
gutter-related endoleaks, and their presence did
not correlate to increased risk for the growth of
the aneurysm sac.
In patients where balloon angioplasty of the
proximal attachment site, covered extension cuff,
Palmaz stent, and EndoAnchors are not successful in resolution of Type IA endoleak during
EVAR and there is insufcient space between
endograft and renal arteries, embolization may
provide an alternative treatment option from femoral approach. A reverse curve catheter can be
used to probe the edge of the stent graft to gain
access into the perigraft endoleak space. A microcatheter is advanced into the perigraft space for
embolization using coils and liquid embolic
material (NBCA glue and Onyx).
References
1. Ullrey BW, Tran K, Itoga NK, Dalman RL, et al.
Natural history of gutter related type IA endoleaks
after snorkel/chimney endovascular repair. J Vasc
Surg. 2017;65(4):981–90.
2. Chen J, Stavropoulos SW.Management of endoleaks.
Sem Int Rad. 2015;32(3):259–64.
Exposed Graft intheGroin
Following Crossover FemoralFemoral Graft andAorto-Uniiliac
Stent Graft
65
Physical Examination andHistory
A 74-year-old male was found to have a large
(8.8×9.8cm AP/transverse) diameter abdominal
aortic aneurysm (AAA) and a 3.7cm left common iliac artery aneurysm detected on CTA of
abdomen and pelvis on September 2009. Medical
comorbidities included history of hypertension
and congestive heart failure (left ventricular ejection fraction 20%). Past surgical history included
left upper lobe lobectomy for carcinoma of the
lung.
Procedure
Patient underwent aortography and pelvic arteriography with preoperative placement of
Amplatzer occluder plug at the origin of left
hypogastric artery (Fig. 65.1). Endovascular
aneurysm repair (EVAR) was performed using
Talent graft (Medtronic, Dublin, Ireland) with
main body 34×18×155, contralateral graft limb
14×16×105, and two extension left iliac limbs
of 18×12×80 and 12×12×80 and a right iliac
extension limb of 18×14×75 and on the right
side 28× 28 × 40 aortic cuff as a “bell bottom”
technique. Capture of the gate could not be performed by retrograde femoral sheath, and a left
brachial artery approach using a 7F 100-cm-long
vertebral guiding catheter was used. Completion
arteriogram following EVAR showed successful
exclusion of the AAA without endoleak. A postoperative CTA of the abdomen and pelvis before
discharge showed Type III endoleak (Fig.65.2)
due to disruption of malalignment of left iliac
endograft limbs. Attempted relining of the left
iliac limb on September 10, 2009, was unsuccessful; therefore the graft was converted to
aorto-uniiliac formation by using three AneuRx
cuffs. A crossover femoral-femoral graft using
8 mm PTFE INTERING® prosthesis was used
(W.L.Gore, Newark, DE).
Graft exposure in the left groin occured following removal of the sutures 7 days later. Patient
was taken back to the operating room, and a new
8mm graft in a different tunnel was performed.
The previously placed femoral- femoral graft was
removed at the suprapubic level, and an 8 mm
graft was sutured end to end to the graft which
had been placed about a week earlier; this graft
was brought anterolaterally on the anterolateral
surface of the iliac crest in a subcutaneous plane
and anastomosed to the mid supercial femoral artery in the subsartorial canal. At the same
time, sartorius myoplasty was performed, and
the left groin healed following application of the
wound vac. Follow-up imaging study showed
no evidence of endoleak with patent crossover
femoral-femoral graft (Fig. 65.3). Patient died
14 months following EVAR from congestive
heart failure.
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_65
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