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69 Ruptured Abdominal Aortic Aneurysms inPatient withType III Endoleak Following Endovascular…
the need for lifelong surveillance. Certain anatomic features such as aortic angulation and large
abdominal aortic aneurysm size may increase the
likelihood of future complications. Patients must
be reminded of the need for lifelong
surveillance.
References
1. Maleux G, Poorteman L, Lanen A, Lebes BS,
et al. Incidence, etiology, and management
of type III endoleak after EVAR. J Vasc Surg.
2017;66(4):1056–64.
2. Rubinstein C, Bitez G, Davenport DL, Winkler M,
et al. Abdominal compartment syndrome associated
with endovascular and open repair of ruptured abdominal aortic aneurysm. J Vasc Surg. 2015;61:648–54.
3. US Food and Drug Administration Safety Report,
update on risk of type III endoleaks with use of
Endologix AFX endovascular AAA graft systems:
FDA safety communication, 10/28/2019.
4. Rothenberg KA, Harris JC, Prentice HA, Hsu JH,
et al. Risk of reintervention with Endologix AFX
endovascular abdominal aortic aneurysm systems in
an Integrated Health Care System. J Coll Am Surg.
2019;229(4):Supp1:S334.
5. Chang H, Hadro NC, etal. The progression of billowing of Endologix AFX2 abdominal aortic aneurysm
device as a precursor for the rupture of an abdominal
aortic aneurysm. Ann Vasc Surg. 2019;54:335.e11–4.
Ruptured Abdominal Aortic
Aneurysm duetoType IB Endoleak
70
Physical Examination andHistory
A 75-year-old female came to the emergency
room on March 2012 with severe pain in the
right lower extremity as well as right lower
quadrant of the abdomen. She was a resident of
a nursing home and had recently been discharged from the hospital following acute exacerbation of oxygen- dependent chronic
obstructive pulmonary disease (COPD). Past
medical history was positive for hypertension,
congestive heart failure, and falls secondary to
back and lower extremity pain as a result of
compression fracture of T12 vertebral body.
Past surgical history included debrillator and
pacemaker placement. In 2005, patient underwent endovascular aneurysm repair (EVAR)
with a Zenith graft at an outside hospital, and
records from the vascular surgeon’s clinic
revealed that she was followed up for 6 months
with abdominal aortic ultrasound. There was no
CTA imaging following her index operation.
Emergency CTA scan of the abdomen and pelvis showed ruptured right common iliac aneurysm (large) and a Type IB endoleak and
retroperitoneal hematoma (Fig.70.1).
Fig. 70.1 CTA of the abdomen and pelvis showing ruptured right iliac aneurysm sac secondary to Type IB endoleak
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_70
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70 Ruptured Abdominal Aortic Aneurysm duetoType IB Endoleak
Procedure
Patient was taken to the operating room as an emergency, and 7 F sheath was inserted in the right
femoral artery. An angle stiff glidewire (035–
180cm long) was advanced into the stent graft, and
aortogram was obtained which showed extravasation of the contrast adjacent to the common iliac
artery/stent graft junction. Using Kumpe catheter
and glidewire, access was obtained into the right
hypogastric artery, and both branches (anterior and
posterior) were catheterized. Tornado coils (two
each) 6×3 and 8×4 were deployed in both anterior and posterior branches resulting in complete
occlusion of the hypogastric artery and its branches.
Angle stiff glidewire was replaced by Lunderquist
wire, and an iliac extension limb 16 × 13 ×124
(Endurant) followed by 18× 13 × 82 (Endurant)
was deployed as an extension into the proximal
external iliac artery. Following balloon angioplasty,
completion arteriogram was obtained which
showed possible Type III endoleak; therefore
another iliac extension limb (16 × 13 × 93) was
deployed with resolution of endoleak (Fig.70.2).
Fig. 70.2 Coil embolization of the branches of right hypogastric artery and placement of right iliac extension limbs
with satisfactory repair
References
313
Patient developed dilutional coagulopathy with
mildly distended abdomen. Coagulopathy was corrected by fresh frozen plasma platelet transfusion.
However, patient could not be weaned off the ventilator, and patient’s family decided hospice care as
per her advanced directive. She died 3 weeks following repair of ruptured right iliac aneurysm.
Discussion
Rupture of AAA in a patient with prior EVAR
remains a lethal problem [1, 2]. Cho etal. reported
that existing endograft provides neither acute nor
1-year survival benet after ruptured AAA repair.
Cho etal. reported 20% operative mortality with
endovascular repair and 38.1% with open repair
(p= 0.27) in patients who had rupture of AAA
with prior EVAR [1]. Catenescu et al. reported
121 patients from 2001 to 2015 with group A
consisting of 17 patients who had a prior endograft repair and 104 who had a de novo rupture of
AAA.They reported mortality of 44.7% with a
previous endograft group and 42.3% in de novo
group (p not signicant) [2].
Ruptured AAA in a patient with prior endo-
graft should be managed by endovascular
approach or open approach depending upon the
ndings of CTA abdomen and pelvis. In this
patient, rupture of AAA was due to large Type IB
endoleak and probably not well seen on ultrasound studies. It is possible that a CTA scan of
the abdomen and pelvis may have detected Type
IB endoleak prior to its rupture as renal function
in this patient was satisfactory.
References
1. Cho JS, Park T, Kim JY, Chaer RA, et al. Prior
endovascular aneurysm repair provides no survival
benet when the aneurysm ruptures. J Vasc Surg.
2010;52(5):1127–34.
2. Catenescu I, Long G, Bove P, Khoury M, et al.
Rupture of abdominal aortic aneurysm in patients with
and without antecedent endovascular repair. Ann Vasc
Surg. 2017;39:99–104.
Ruptured Abdominal Aortic
Aneurysm Secondary toDelayed
Type 1A Endoleak
71
History andProcedures
An 83-year-old male underwent endovascular
aneurysm repair (EVAR) with AneuRx graft for a
6.5 cm abdominal aortic aneurysm (AAA) with
45–60° aortic neck angulation on May 19, 2008,
under spinal anesthesia. Main body
(28×16×165mm) was deployed from the right
femoral artery and contralateral iliac limb
(16× 16 × 135 mm). Another left iliac extension
limb (16×16×115mm) was also deployed. Right
iliac extension limb (16×16×115mm) was necessary to extend the graft just proximal to the right
common iliac artery bifurcation. Following angioplasty of the aortic neck and overlapping zones
with Reliant™ balloon (Medtronic, Dublin,
Ireland), completion aortogram was performed
which showed Type IA endoleak. After another
attempt at aortic neck angioplasty, an aortic cuff
28×40mm (AneuRx) was deployed, and completion run showed marked decrease in Type IA
endoleak. Patient underwent follow-up CTA of the
abdomen and pelvis 3 days later which showed
Type IA endoleak. Patient was taken back to the
operating room and a Palmaz stent 39× 10mm
was deployed using a 16F sheath in the right femoral artery over a 28mm ×4cm Z-MED Braun
balloon. Completion run showed satisfactory resolution of Type IA endoleak.
Patient had a CTA of the abdomen and pelvis
performed 3 years later which showed satisfactory exclusion of the endoleak, but there was evi-
dence of graft migration about 1 cm below the
left renal artery (Fig.71.1). Patient came for follow- up for 3years (till 2011) and underwent follow- up imaging with CTA of the abdomen and
pelvis alternating with abdominal aortic ultrasound at six monthly intervals. CTA of the abdomen and pelvis in January 2011 showed aneurysm
sac 5.9×5.9cm with no evidence of endoleak.
Patient was lost to follow-up till he came to
the emergency room on February 19, 2019,
(Fig. 71.2) with syncope. CTA of the abdomen
and pelvis showed ruptured AAA with Type I and
Type III endoleak with distal migration of the
AneuRx graft. In addition, there was poor lling
of the right renal artery, possibly from a large retroperitoneal hematoma. He was taken to the
hybrid operating room, right femoral artery was
exposed, and a percutaneous access to the left
femoral artery was obtained with insertion of 6F
sheath. On the right side, glidewire was
exchanged with Lunderquist wire using Kumpe
catheter, and a 16F sheath was deployed. Two
aortic cuffs, rst cuff 28× 28× 70 and second
aortic cuff 28 × 28 × 49 were deployed.
Completion aortogram showed persistence of
Type IA endoleak. Four EndoAnchors (HeliFx)
at the aortic neck was followed by placement of
Palmaz stent. As the aortic neck was short and
angulated another (third) aortic cuff 32×32×49
was deployed to resolve Type IA endoleak
(Fig.71.3). Completion run showed partial coverage of the left renal artery by the third aortic
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_71
315
316
Fig. 71.1 CTA showing EVAR with Palmaz stent at the aortic neck with slight migration of the AneuRx graft
71 Ruptured Abdominal Aortic Aneurysm Secondary toDelayed Type 1A Endoleak
Fig. 71.2 Rupture of AAA secondary to Type IA and Type III endoleak
cuff; however there was resolution of Type IA
endoleak (Fig. 71.4). The postoperative hemoglobin was 6g% with a hematocrit of 16. He was
given six units of packed red cells, four units of
nursing home for permanent hemodialysis. On
October 2, 2019, patient presented with syncope
and expired within the emergency room of the
hospital.
fresh frozen plasma, ten units of platelets, and
calcium administration as patient developed dilutional coagulopathy. In spite of adequate urine
Discussion
output for 3days, patient developed acute kidney
injury and had to be placed on hemodialysis
through a via temporary Quinton catheter. We
then placed a tunneled dialysis catheter on
February 16, 2019, and patient was discharged to
Coverage of one and occasionally both renal
arteries may be required to facilitate EVAR in
patients who are not candidates for open repair.
Tanious et al., using VQI data set (2013–2018),
Invited Commentary fromFaisal Aziz, MD, DFSVS, FACS, andMarvin Chau, BS
317
Fig. 71.3 Intraoperative aortogram showing persistent
Type IA endoleak
selected patients who had undergone EVAR for
ruptured AAA [1]. Of 2278 patients with ruptured AAA, 2230 had no renal coverage, 30 had
single renal artery coverage, and 18 had coverage
of both renal arteries. On multivariant regression
analysis, bilateral renal artery coverage was associated with increased odds of in-hospital mortality (OR 5.7), permanent dialysis/30-day death
(OR 9.5), and permanent dialysis (OR 47.5).
Single renal artery coverage increased the odds to
increase the odds of permanent dialysis/ 30-day
mortality (OR 2.8). From their observations, they
concluded that bilateral renal artery coverage in
ruptured AAA signicantly increases in-hospital
mortality and lowers long-term survival. Single
renal artery coverage increases the risk of permanent dialysis/30-day death primarily due to its
effect on permanent hemodialysis. It does not
signicantly affect the in-hospital mortality or
1-year survival it may be a viable option in select
patients with AAA.In this patient intentional left
renal artery coverage resulted in permanent
hemodialysis with patient’s survival for eight
more months.
Fig. 71.4 Resolution of Type 1A endoleak with partial
coverage of the origin of left renal artery
This case also illustrates that a signicant
number of patients do not come for regular follow- up following EVAR. This patient stopped
coming for imaging studies 3years following his
index operation. Hicks et al. evaluated 11, 309
patients (2003–2015) who underwent elective
EVAR with 78% in-person follow-up, 11% phone
call follow-up, and 11% loss to follow-up [2].
Patients who are lost to follow-up had worse survival outcomes (84.9% vs 91.9% long rank,
P<.001).
Invited Commentary fromFaisal
Aziz, MD, DFSVS, FACS, andMarvin
Chau, BS
The past two decades have seen an endovascular
revolution, with endovascular repair of the
abdominal aortic aneurysms (EVAR), largely
318
71 Ruptured Abdominal Aortic Aneurysm Secondary toDelayed Type 1A Endoleak
replacing traditional open abdominal aortic aneurysm repair as the rst line modality to treat
abdominal aortic aneurysms. This case highlights
a few important teaching points:
1. Importance of adhering to IFU in patients
with challenging anatomy
A review of literature shows that strong
body of evidence supports strictly adhering to
IFU protocol for aortic endografts. Patients
who undergo EVAR, per the IFU instructions,
tend to have improved outcomes as compared
to those who undergo EVARs without strictly
adhering to IFU criteria [3]. In this particular
case, aortic angulation may have precluded
the use of endograft at the time of index operation. One can argue that choosing open aortic
aneurysm repair over EVAR at the time of initial operation could have prevented the longterm complications.
2. Importance of realizing the impact of Type 1A
endoleak on completion angiograms
The fundamental concept of EVAR is that
there should not be a Type 1A endoleak at the
completion of the operation. Presence of
Type 1A endoleak is considered by most
experts as the equivalent of if the aneurysm
was never repaired [4]. More importantly, a
thoughtful consideration should be given to
determine the exact cause of the Type 1A
endoleak at the time of the index operation.
Graft undersizing, lack of adequate seal zone,
and presence of large amount of thrombus are
important causes of such endoleaks. The
cause of Type 1A endoleak should be determined and treated adequately at the time of
diagnosis. Ideally, no patient undergoing
EVAR should leave the operating room with
Type1 endoleak.
3. Ensuring long-term follow-up with imaging
studies
Patient selection at the time of choice of
operation (EVAR vs open AAA repair) should
consider several factors into account. Patients’
compliance with regular follow-up appointments, along with commitment to obtain
CTAs at the follow-up appointments is crucial. Patients who are lost to follow-up after
EVAR have been shown to have worst outcomes [2]. For patients, who are considered
unreliable for long-term commitment to
follow- ups, open abdominal aortic aneurysm
may be preferable.
To summarize, this case highlights several
important teaching points, which should be considered in anatomic selection for EVAR, addressing Type 1 A endoleaks on completion angiograms
in the operating room and stressing the importance of long-term follow-up. In patients with
unfavorable anatomy and lack of commitment to
long-term follow-up, open AAA repair may be
preferable to EVAR.
References
1. Tanious A, Boitano LT, Wang LJ, Shames ML, etal.
Renal artery coverage during endovascular aneurysm repair for ruptured abdominal aortic aneurysm. Ann Vasc Surg. https://doi.org/10.1016/J.
avsg.2019.05.005.
2. Hicks CW, Zarkowsky DS, Bostock IC, Stone DH,
et al. Endovascular aneurysm repair in patients who
have lost to follow up have worse outcomes. J Vasc
Surg. 2017;65(6):1625–8.
3. Charbonneau P, Hongku K, Herman CR, Habib M,
Girsowicz E, Doonan RJ, etal. Long-term survival after
endovascular and open repair in patients with anatomy
outside instructions for use criteria for endovascular
aneurysm repair. J Vasc Surg. 2019;70:1823–30.
4. Schlosser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen
HJ, Moll FL, etal. Aneurysm rupture after EVAR: can
the ultimate failure be predicted? Eur J Vasc Endovasc
Surg. 2009;37:15–22.
Endovascular Repair forRuptured
Abdominal Aortic Aneurysm
inaPatient withAntecedent
Endograft
72
Physical Examination
An 81-year-old male presented to the emergency
room of the hospital visiting from out of state on
July 8, 2017, with severe back pain. CTA of the
abdomen and pelvis showed probable Type III
endoleak (separation of component parts) and
possible Type IA endoleak (Fig.72.1).
Procedure
Patient was emergently taken to the operating
room because of signicant hypotension a
32mm ×2 cm aortic balloon (Z-MED, Braun)
was inated through a 16F sheath. On the left
side a 5F sheath was inserted percutaneously. On
the right side, an angle stiff glidewire (035–
180cm long) was advanced, but it could not be
advanced into the body of the endograft as it
lodged in the aneurysm sac from the separated
components of the endograft (Type III endoleak).
With the help of Kumpe catheter, glidewire was
exchanged for Lunderquist wire and a
16×20×93mm Endurant
Ireland) iliac limb was deployed to close the Type
III endoleak. For management Type IA endoleak,
a 28× 49 mm Endurant cuff was deployed followed by angioplasty by Reliant™ balloon
(Medtronic). As the Type IA endoleak persisted,
a 10×40mm Palmaz stent over a 32-mm-×4-cmlong Z-MED balloon was deployed through the
®
(Medtronic, Dublin,
16F sheath. Completion run showed resolution
of Type IA and Type III endoleak (Fig.72.2).
Because of the development of abdominal
compartment syndrome, a left ank incision
was made to drain the retroperitoneal space, and
400 cc blood mixed with serosanguinous uid
was removed followed by application of a
wound vac. Removal of wound vac followed by
secondary wound closure was performed on
14th postoperative day. In the postoperative
period, patient developed new onset of atrial
brillation which was managed with low-dose
beta blockers and warfarin. Postoperative CTA
showed resolution of Type IA and Type III
endoleak with satisfactory exclusion of the
aneurysm and marked decrease in the retroperitoneal hematoma (Fig.72.3).
Review of records from out of state hospital
showed that on June 1, 2006, patient underwent
endovascular aneurysm repair (EVAR) for a 9cm
infrarenal abdominal aortic aneurysm (AAA)
using Cook endoprosthesis. His medical comorbidities included coronary artery disease (CABG
twice), gout, hypertension, Type II diabetes mellitus, and hyperlipidemia.
Patient moved back to the state of his resi-
dence in August 2017 and was followed by a vascular surgeon. He underwent CTA scan of the
abdomen and pelvis in March 2018 which
showed recurrence of Type IA endoleak. He
underwent preoperative stenting of the renal
arteries with iCAST™ stent (Atrium) on April 5,
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_72
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72 Endovascular Repair forRuptured Abdominal Aortic Aneurysm inaPatient withAntecedent Endograft
320
Fig. 72.1 CTA showing ruptured AAA with stent graft and retroperitoneal hematoma