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Part XVII
Endovascular Aneurysm Repair
for Ruptured Abdominal Aortic Aneurysm
Endovascular Aneurysm Repair
forRuptured Abdominal Aortic
Aneurysm
68
Physical Examination
A 77-year-old male presented to the emergency
room with severe abdominal and back pain and
vomiting. CTA abdomen and pelvis showed ruptured infrarenal abdominal aortic aneurysm
(AAA) with retroperitoneal hematoma. AAA
measured 9.7×9.2cm (ap/transverse diameter).
The aortic neck angulation was 45–60°
(Fig.68.1).
Procedure
He underwent emergency endovascular aneurysm repair (EVAR) on June 10, 2016, with
Endurant (Medtronic, Dublin, Ireland) graft with
main body deployed from the right side
(36 × 16 × 166). A multipurpose catheter was
used to capture the contralateral gate, and a
16×24× 124 contralateral limb was deployed.
On the right side, iliac extension limb of
Fig. 68.1 CTA showing rupture of large AAA with retroperitoneal hematoma
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_68
301
302
Fig. 68.2 Intraoperative arteriography and deployment of endograft
68 Endovascular Aneurysm Repair forRuptured Abdominal Aortic Aneurysm
Fig. 68.3 CTA 1 month later showing patent endograft with retroperitoneal hematoma
16×24×124 was also deployed. Completion run
showed satisfactory exclusion of the aneurysm.
At the end of the operation, abdomen became
slightly distended and tense, but as the peak
inspiratory pressure was not elevated, abdomen
was not re-explored for possible abdominal compartment syndrome.
A follow-up CTA of the abdomen and pelvis 3
weeks later showed that the size of the aneurysm
sac was 9.6 × 9.2 cm with a possibility of an
expanding retroperitoneal hematoma with possi-
ble active hemorrhage in the pelvic space
(Fig.68.2). Patient therefore underwent abdominal aortography on July 11 which showed satisfactory exclusion of the aneurysm without any
endoleak and without any extravasation
(Fig.68.3). Patient underwent follow-up duplex
ultrasound of the abdomen which showed no evidence of endoleak and a stable aneurysm sac.
Patient underwent a follow-up CTA scan of the
abdomen and pelvis in February 2017 which
showed the aneurysm sac to measure 9.1×9.2cm
Discussion
Fig. 68.4 Showing satisfactory endograft deployment without endoleak
for EVAR, most experts agree that EVAR-rst
stance is the best for patients in whom the anatomy is suitable for EVAR [1, 2]. A multicenter
trial (IMPROVE trial) conducted in 30 centers
(29 UK, 1 CA) randomized 613 patients with
ruptured AAA: 316 to EVAR-rst strategy (if
aortic morphology was suitable, open repair if
not) and 297 to open repair. The principal 1-year
outcome was mortality; secondary outcomes
were re-interventions, hospital discharge, healthrelated quality of life, cost, quality adjusted life
years, and effectiveness at 1 year. At 1 year, allcause mortality was 41.1% for endovascular
Fig. 68.5 CTA showing no endoleak with reduction of
retroperitoneal hematoma
strategy group and 45.1% for open repair group
with similar re-intervention rates in each group.
They concluded that an endovascular rst strat-
egy for management of rupture AAA does not
with possibility of small Type II endoleak
(Fig. 68.4). The last CTA of the abdomen and
pelvis was performed in November 2019 which
showed satisfactory exclusion of the aneurysm
with no evidence of endoleak, with residual aneurysm sac measuring 9.2×9.2cm (Fig.68.5).
offer a survival benet over 1 year but offers
patients faster discharge with better quality of life
and is cost-effective. Holst etal. reported early
and intermediate outcomes of emergency EVAR
of ruptured infrarenal AAA in 90 consecutive
patients from single institution with a 30-day
mortality of 27% and 1-year mortality of 33%.
They concluded from the retrospective analysis
Discussion
that EVAR is a valid treatment option for rup-
tured AAA [3]. Kapema et al. randomized 116
While many randomized trials comparing EVAR
for ruptured AAAs to traditional open surgical
repair have failed to show a conclusive advantage
patients with ruptured AAA into open and EVAR
with 30-day mortality of 21% after EVAR and
25% for open repair. They concluded that EVAR
303
304
68 Endovascular Aneurysm Repair forRuptured Abdominal Aortic Aneurysm
may be more effective for ruptured AAA but its
costs are prohibitive [4].
References
1. Mansour MA, Zwibelman H.Endovascular repair of
ruptured abdominal aortic aneurysm. In: Hans SS,
Shephard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction:
a practical approach. Boca Raton: CRC Press; 2018.
p.63–8.
2. McPhee J, Eslami MH, Arous EJ, Messing
LM. Endovascular treatment of ruptured abdominal
aortic aneurysms in the United States (2001–2006): a
signicant survival benet over open repair is independently associated with increased institutional volume. J Vasc Surg. 2009;49:817–26.
3. Holst J, Resch T, Ivanceau K, Bjorses K. Early and
intermediate outcome of emergency endovascular aneurysm repair of ruptured infrarenal abdominal aortic aneurysm: a single center experience of
90 consecutive patients. Eur J Vasc Endovasc Surg.
2009;37:413–9.
4. Kapema MR, Dijksman LH, Rimerink JJ, DeGroof
AJ, etal. Cost-effectiveness and cost-utility of endovascular verses open repair of ruptured abdominal aortic aneurysm in the Amsterdam Acute Aneurysm Trial.
Br J Surg. 2014;101:208–15.
Ruptured Abdominal Aortic
Aneurysms inPatient withType III
Endoleak Following Endovascular
Aneurysm Repair withEndologix
Graft
69
Physical Examination andHistory
A 65-year-old male was seen in the emergency
room of the hospital with abdominal pain radiating to back on March 2012. Past medical history
was positive for hypertension and acute deep
venous thrombosis affecting right femoral vein
in February 2012. Patient also had a history of
coronary artery disease with a remote myocar-
dial infarction and atrial brillation on warfarin.
Past surgical history revealed that patient had
undergone endovascular aneurysm repair
(EVAR) in July 2011 for an 8 cm transverse
diameter infrarenal abdominal aortic aneurysm
(AAA) at an outside hospital (Figs. 69.1 and
69.2). Endologix graft was used; however the
exact type of Endologix graft could not be identied. Postoperative CTA of the abdomen and
Fig. 69.1 Preoperative CTA showing infrarenal AAA
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_69
305
306
69 Ruptured Abdominal Aortic Aneurysms inPatient withType III Endoleak Following Endovascular…
pelvis in September 2011 showed satisfactory
aneurysm repair with aneurysm sac measuring
8.1 × 7.7 cm with no evidence of endoleak
(Fig.69.3).
Patient underwent emergent CTA of the abdomen and pelvis and abdominal aortography
which showed Type III endoleak without evidence of aneurysm sac rupture.
Fig. 69.2 Intraoperative image showing deployment of
Endologix graft
Procedure
Patient was taken to the operating room and
was given four units of fresh frozen plasma to
correct his INR (3.1). He underwent placement
of two AneuRx (Medtronic, Dublin, Ireland)
cuffs measuring 26 × 26 × 40 mm and
28×28×40mm on March 10, 2012 due to the
lack of thoracic stent graft available in the operating room. In addition, a left iliac extension
limb (AneuRx 20 × 20× 85mm) was placed
and extended to the mid external iliac artery as
the Endologix (Irvine, CA) endograft was only
covering proximal 1.5cm of the left common
iliac arteries. CTA of the abdomen and pelvis in
March 29, 2012, showed aneurysm sac measuring 8.3 × 7.9 cm with resolution of Type III
endoleak. Patient was seen in the outpatient
clinic in April 2012 with symptoms of left hip
claudication which improved gradually. A follow- up CTA scan on November 13, 2012,
showed aneurysm sac measuring 6.2× 7.1 cm
without any evidence of endoleak.
Patient presented to emergency room on
March 13, 2013, with increasing abdominal
pain of 3–4 days duration. In the emergency
room, hisblood pressure was 206/108 mmHg.
An emergency CTA scan of the abdomen and
Fig. 69.3 Postoperative CTA showing satisfactory endograft (3 months later)
Discussion
Fig. 69.4 Recurrent Type III endoleak with ruptured AAA with endograft
pelvis showed Type III endoleak (Fig. 69.4).
He was administered three units of fresh frozen
plasma as INR was 3.7 and taken to the operating room where bilateral femoral access was
obtained and 7 F sheaths were inserted. On
the right side, an exchange length Glidewire®
(Terumo, Somerset, NJ) was advanced over the
Kumpe catheter (Cook Medical, Bloomington,
IN). Glidewire® was removed and replaced
by Lunderquist® wire (Cook Medical); on
the left side, an Omniush marker catheter
(AngioDynamics, Latham, NY) was passed
through the left femoral sheath. We were able
to negotiate the disconnected components of
Endologix graft with the help of Glidewire and
Kumpe catheter. Type III endoleak was sealed
using 30×30×150mm valiant thoracic endograft followed by Reliant™ balloon (Medtronic)
Fig. 69.5 Deployment of Valiant thoracic endograft for
control of Type III endoleak
angioplasty (Fig.69.5). However patient developed coagulopathy (INR 2.8, PTT 74, platelet
Discussion
count 98,000, and hemoglobin 7.2g); ten units
of packed red cells, factor VII, and cryoprecipitate were given. As the peak respiratory pressure
was markedly elevated (55 cm water), patient
underwent decompressive laparotomy for
abdominal compartment syndrome, but patient
remained hypotensive and expired 12 hours
after repair from disseminated intravascular
coagulation.
Maleux etal. identied 20 patients (2.1%) with
25 Type III endoleaks among 965 EVAR (1995–
2014). In most cases the underlying mechanism
was disconnection of the stent graft components
(56%), and a fabric defect was found in 44%
patients. Type III endoleak may appear early or
late after initial EVAR [1]. In the study reported
by Maleux etal., 10% of their patients presented
307
308
69 Ruptured Abdominal Aortic Aneurysms inPatient withType III Endoleak Following Endovascular…
with a rupture or an aortoduodenal stula as the
rst sign of Type III endoleak. They treated 22
(88%) Type III endoleaks with endovascular
technique and 3 (12%) by open surgical conversion [1].
CTA angiography is considered to be the best
diagnostic tool to identify a Type III endoleak
though plain abdominal lms can conrm a disconnection of a stent graft limb and its components. Treatment of a Type III endoleak includes
placement of a covered stent across the graft
components. If the fabric tear is at the oor
divider, relining with conversion of the graft to
aorto-uniiliac conguration is a better option. In
spite of technically satisfactory repair, Type III
endoleak may reoccur in a number of cases as
was the case in the present report.
Abdominal compartment syndrome following
open or endovascular repair of a ruptured AAA
occurs as a result of increased intra-abdominal
pressure due to massive volume resuscitation.
Due to increased intra-abdominal pressure and
extrinsic compression of inferior vena cava,
venous return is compromised with resultant
decrease in the cardiac output and increase in the
systemic vascular resistance. Rubinstein et al.
reported 73 patients with abdominal compartment syndrome, 44 following open repair of ruptured AAA and 29 following EVAR with overall
mortality of 42% [2]. The authors observed that
patients with abdominal compartment syndrome
following EVAR for ruptured AAA had higher
intraoperative blood and blood product requirements. They hypothesized that continuous hemorrhage from lumbar and inferior mesenteric
artery through the ruptured aneurysm sac may be
responsible for this difference. They recommended open ligation of inferior mesenteric
artery and lumbar arteries in patients developing
abdominal compartment syndrome after EVAR
for ruptured AAA [2]. The incidence of abdominal compartment syndrome after EVAR of ruptured aneurysm is 5.5–8% [2]. But rates as high
as 21% had reported using intra-abdominal pressure measurements from a indwelling urinary
catheter. Patients developing abdominal compartment syndrome after repair of ruptured AAA
have a higher incidence of bowel ischemia, renal
failure, respiratory failure, and sepsis [2]. Medical
therapy of abdominal compartment syndrome
includes neuromuscular blockade, positive endexpiratory pressure (PEEP), albumin, and intravenous diuretics. If abdominal compartment
syndrome does not respond to medical therapy,
decompressive laparotomy should be performed,
and the abdomen should be kept open avoiding
adhesions between the intestine and abdominal
wall; a vacuum-assisted wound closure is
undertaken.
Recently, FDA has sent a notication (October
28, 2019) regarding greater risk of Type III
endoleak with Endologix AFX® and Endologix
STRATA device [3]. Therefore careful long-term
follow-up with imaging studies is necessary in all
patients to prevent rupture of AAA following
EVAR.According to the FDA warning, this close
follow-up is mandatory in patients in whom
Endologix device was used.
Invited Commentary fromPaul
G.Bove, MD, FACS, FSVM
Unfortunately, in the domain of vascular care, all
therapies have a failure rate that is at times not
easily predicted. Specically, in dealing with
endovascular repair of abdominal aortic aneurysms, there are multiple forms of failure that can
occur, some of which are early after repair and
some may not present for years after implantation. Because of this lack of certainty of success,
lifelong surveillance is required of patients who
undergo aortic stent graft implantation. This is
not unlike other vascular procedures that can fail
years after completion. Most importantly, as in
other realms of vascular surgery, when problems
can be identied through surveillance and treated,
this can result in a survival advantage as in the
case of aortic stent graft repair.
The authors describe a complex case of a
patient with a Type III endoleak following
implantation of an Endologix AFX graft, initially
treated approximately 8months following initial
treatment with two overlapping AneuRx aortic
cuffs to treat a Type IIIA endoleak as well as an
iliac extension. Unfortunately, 1 year after the
Invited Commentary fromPaul G.Bove, MD, FACS, FSVM
309
primary secondary intervention, the patient presented with rupture, and a Valiant thoracic graft
was placed and a laparotomy required for abdominal compartment syndrome with the patient
expiring shortly thereafter from coagulopathy.
Their case represents a real-world experience of
the complexities that are faced, the decisions that
are necessary, and the resources that are needed
to treat patients as we try to create innovative
ways to treat uncommon and sometimes unforeseen problems that present to us in emergent
scenarios.
In recent years, there have been numerous
communications from the FDA regarding the
Endologix aortic stent graft systems. The AFX
Endovascular AAA System received approval in
2011. These grafts were produced between 2011
and 2014 with implantations stopping in 2016. In
July 2014, the initial AFX with Strata material
was replaced by the AFX with Duraply material.
In February 2016, the Duraply material was further modied, and AFX2 became available. In a
physician communication in December 2016,
Endologix requested all AFX Strata devices be
removed from hospital inventory due to an
increased number of Type III endoleaks. There
also have been modications to the original recommendations in the instructions for use specically with recommendations regarding aortic cuff
overlap. On October 15, 2018, the FDA issued a
Class 1 Recall of the Endologix AFX
Endovascular System. This was following previous communications to providers in September
2017 and again in June 2018 warning about
increased Type III endoleaks.
The most recent communication from the
FDA on October 28, 2019 [3], was in response to
recent abstract data presented from the Kaiser
Integrated Health System on their experience
with all AFX systems identifying a 2.5% incidence of Type II leaks at 2years in their cohort of
603 patients [4]. Admittedly, further analysis
needs to be performed, and the limitations of the
study as presented are acknowledged with the
need for further data. I have no doubt that both
the FDA and Endologix Inc. have the best interest
of the patient in mind with their vigilant communications and oversight in this complex arena.
Another unique characteristic of the
Endologix AFX Endovascular System is its basic
structure with an endoskeleton that allows the
outer fabric “billow” out. This phenomenon is
noted routinely and is to some degree an expected
nding and follow-up CT studies. Some authors
have suggested that in certain cases this phenomenon could contribute to graft failure [5]. The
most important aspect of billowing is twofold.
For the patient who is stable, it is necessary to
look specically at the radiographic features
from serial exams to identify changes which may
suggest progression to graft failure. In the case
of the patient who does require a secondary
intervention, extensive billowing and if it is in
conjunction with aortic angulation may make the
passage of guidewires more complex. It is essential to insure that guidewire passage on secondary procedure is within the endoskeleton and not
through it.
There are some real-world experiences that
have been used to assist in treating the type of
IIIa endoleaks that can be encountered that are
specic to the Endologix products. Because of
the endoskeleton, a higher degree of attention is
required at the time of initial guidewire passage.
Adjuncts such as large diameter balloon passage
along guidewires to insure proper positioning
within the endoskeleton are commonly described.
Overlapping aortic cuffs as utilized in the presented case, thoracic aortic segments, or
Endologix aortic segments have all been
described. At the time of presentation and repair,
it is important to insure that there are no other
failure modes present such as a Type IIIb leaks or
problems at either the aortic or iliac seal zones
which could predispose a future Type I problem.
This may require placement of additional aortic
or iliac extensions or could be treated with complete relining utilizing a full aortic stent graft system from Endologix or another manufacturer. On
occasion, explantation could be utilized if needed
with open reconstruction.
With this heightened awareness of the problem in general and specic to the Endologix
product, the most important takeaway is the
importance of understanding the instructions for
use and potential limitations of any product and