Late type III endoleak from fabric tears of a zenith stent graft: report of a case

Exploring Type IIIb Endoleaks: A Literature Review to Identify Possible Physical Mechanisms and Implications

Endoleaks are common complications following endovascular aneurysm repair (EVAR). They can be classified into low-pressure and high-pressure endoleaks. High-pressure endoleaks, which include Type I and Type III endoleaks, pose a significant risk of rupture and require urgent treatment. The aim of our study is to review published case reports and case series to assess the impact of Type IIIb endoleaks in EVAR and to identify possible mechanisms contributing to these endoleaks. This review targeted case reports and case series published between January 1998 and December 2022. A total of 62 case reports and case series were identified, encompassing 156 patients with Type IIIb endoleaks. Data collection was performed by three consultants who thoroughly discussed each report before registering it into an analyzable data set. Our analysis revealed that, beyond material imperfections, certain endograft configurations or conformations, endograft redundancy, and the physical forces acting on the grafts may lead to increased stress on specific parts of the endografts, potentially exceeding their design limits. Factors contributing to redundancy and unfavorable conformation of the endograft include secondary interventions for any cause (such as other types of endoleaks), EVAR performed outside the instructions for use (IFUs), endograft migrations, or larger initial aneurysm diameter.

Incidence, Long Term Clinical Outcomes, and Risk Factor Analysis of Type III Endoleaks Following Endovascular Repair of Abdominal Aortic Aneurysm

OBJECTIVE

To assess the real world incidence, outcomes, and risk factors of type III endoleaks (TIIIEL) after endovascular aneurysm repair (EVAR).

METHODS

This was a single centre, retrospective, observational, cohort study. All patients with abdominal aortic aneurysms (AAAs) receiving EVAR between 1994 and 2020 were collected prospectively and reviewed. The primary outcome was the cumulative incidence and impact on survival of TIIIELs, either defined as disconnections of modular graft components (TIIIaEL) or fabric defects (TIIIbEL). Secondary outcomes included risk factor analysis evaluating baseline morphological and stent graft details, as well as a comparison of TIIIaEL and TIIIbEL.

RESULTS

In total, 2 565 EVARs were performed and 95 (3.7%) TIIIELs were diagnosed at a median interval of 49.5 months (interquartile range [IQR] 19.4, 67.6). Estimated TIIIEL incidence at five years was 6.8%, 2.2%, and 3.6% for first and second generation, third and fourth generation, and fifth and sixth generation, respectively. The survival rate in patients without any high flow endoleak was 88.0%, 67.9%, 56.9%, and 52.1%, while in TIIIEL patients it was 98.6%, 77.2%, 49.8%, and 32.3% at one, five, 10, and 15 years, respectively (p = .77). The distribution of TIIIaEL and TIIIbEL was 70.5% and 29.5%, respectively. TIIIbEL received a higher rate of open treatment (28.6% vs. 7.5%; p = .005) and device or procedure related re-interventions (35.7% vs. 13.4%; p = .013). Fourteen (15.4%) recurrent TIIIELs were diagnosed at a median of 16.8 months (IQR 7.6, 32.1). Old generation endografts (hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 - 3.4; p = .002) and non-proprietary extensions (HR 3.6, 95% CI 1.9 - 6.8; p < .001), and angulated and calcified aneurysm neck (HR 3.6, 95% CI 1.2 - 10.6; p = .017) were risk factors for TIIIEL. Every 10 mm maximum AAA diameter increase presented a 1.4 fold higher risk of TIIIEL.

CONCLUSION

TIIIEL is a severe condition that is often fatal if left untreated. Old endografts, the implantation of non-proprietary extensions, large AAAs, and angulated and calcified necks are risk factors for TIIIEL that require careful follow up due to the high rate of recurrence.

Occurrence and outcomes of type 3 endoleaks in endovascular aortic repair within the Vascular Quality Initiative database

Objectives

Type 3 endoleaks (T3ELs) represent a lack of aneurysm protection from systemic pressure. Previous studies have found a ~2% incidence of T3EL after standard infrarenal endovascular aneurysm repair (EVAR); however, no prior studies with new-generation devices have been able to determine an association between T3EL and clinical outcomes. Here we examine T3EL within the Society for Vascular Surgery Vascular Quality Initiative (VQI) to define rates of occurrence, rates and modes of reintervention, and clinical consequences of these endoleaks.

Design and setting

Participants receiving infrarenal EVAR in the VQI from January 2003 to September 2018 were analyzed in a retrospective cohort study.

Participants

Of 42 246 entries in the EVAR procedural registry, 41 604 had complete procedural information and were included in analysis. Of these, 36 082 had long-term follow-up, and 26 422 had follow-up (9-21 months per VQI reporting standards) with complete endoleak data recorded.

Interventions

All patients included in this study underwent an infrarenal EVAR.

Results

Within the VQI database, the rate of T3EL in infrarenal EVAR during index hospitalization was 0.37% (n=157/41 604), of which 85% were due to midgraft separation and 15% were due to fabric disruptions. Out of the 157 index hospitalization T3ELs, 4.5% (n=7) received procedural reintervention during that hospitalization, which accounted for 1% of all index hospitalization reinterventions. During the 21-month follow-up, the rate of incident T3EL was 0.7% (n=205/26 422), which accounted for 5% of all endoleaks seen during follow-up. Reinterventions for incident T3EL at follow-up were done in 30 patients (rate 0.1%), which accounted for 9% of endoleak reinterventions and 3.3% of all reinterventions. The presence of incident T3EL found during follow-up was associated with a significant decrease in 5-year survival (74% vs 80%, respectively; p=0.041) in Kaplan-Meier analysis.

Conclusion

T3ELs rates at placement and follow-up remain low; however, the majority reported in long-term follow-up are incident and these incident endoleaks are associated with decreased survival in EVAR.

Endovascular repair of late type IIIb endoleak after endovascular aneurysm repair: a case report

Background

Type IIIb endoleak is a rare complication after endovascular aneurysm repair (EVAR) and the understanding of type IIIb endoleak is insufficient.

Case presentation

Three elderly patients with previously successfully performed EVARs were sent to our center due to abdominal pain and diagnosed with late type IIIb endoleak. The type IIIb endoleak fabric tears were closed with cuffs or stents by endovascular retreatment. The patients recovered adequately and were discharged from hospital.

Conclusions

Endovascular repair with empirical relining could be a good choice for treatment of late type IIIb endoleak with good prognosis.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1138-8) contains supplementary material, which is available to authorized users.

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 III B endoleak leading to aortic rupture after endovascular repair: analysis of errors in follow up and treatment

Background

The aim of this paper is to describe the case of a patient with a type III endoleak which was misdiagnosed and treated without success as a type I-II endoleak. An incorrect endoleak diagnosis lead to aortic rupture, which could be avoided with a correct diagnosis. Type III B endoleaks presents some diagnostic difficulties, in the case we describe, they were increased by late presentation and poor follow up.

Case presentation

We revised this 89 years old patient history, he underwent EVAR 11 years before, a control scan six month after surgery, showed a type I-II endoleak which was still present after first intervention. He was treated with proximal cuff positioning and embolization coils. Eight years after first intervention, a Computed Tomography Angiography (CTA) showed persisting type I-II endoleak so same problem was suspected and patient was treated with another proximal cuff and right iliac extension. A Magnetic Resonance Imaging (MRI) control, six months later, showed an increase of the aneurysm sac size of 12 mm. Two years later patient presented at emergency room at our hospital with malaise, sweating and abdominal pain. Computed Tomography (CT-scan) showed increased abdominal aortic diameter (140 × 130 mm) with rupture and hemoperitoneum. He was treated in urgent fashion with endograft removal and aortic-iliac Dacron graft reconstruction. During surgery three large tears on endograft fabric and a stent suture rupture were observed. After surgery patient was admitted in intensive care unit and died on second postoperative day due to multiorgan failure.

Conclusions

Type III endoleak is an uncommon complication: a correct and prompt diagnosis is mandatory for appropriate treatment After EVAR, and especially in those cases of known endoleak, a correct follow-up is mandatory and in case of diagnostic doubts correct imaging should be performed. Media contrast allergies should not be neglected and should not represent a CTA limitation.

Aneurysm sac enlargement 16 years after endovascular aortic aneurysm repair due to late type IIIb endoleak: A case report

INTRODUCTION

We report a case with delayed aneurysm sac enlargement 16 years after EVAR due to late type IIIb endoleak.

PRESENTATION OF CASE

An 84-year-old man was referred to our hospital with an aneurysm sac enlargement after endovascular aortic aneurysm repair (EVAR), which had been performed at another hospital 18 years earlier using the Zenith endograft. Computed tomography (CT), after EVAR had shown significant sac shrinkage. However, the patient presented with delayed aortic aneurysm enlargement due to an assumed endoleak. Duplex ultrasound showed a type IIIb and a type Ib endoleak. We performed a re-intervention with an AFX endograft, for relining due to persistent type IIIb endoleak.

DISCUSSION

Compared with the type IIIB endoleaks discussed in past reports, this case occurred with a much longer delay. Although CT could not identify the type of endoleak, duplex ultrasound led us to diagnose the type IIIb endoleak.

CONCLUSION

Relining using an ePTFE endograft may be considered an effective procedure for type IIIb endoleaks. Duplex ultrasound is useful for determining endoleak types.

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.

Positional Changes of an Endurant Endograft Leading to Simultaneous Ipsilateral Iliac Limb Obstruction and Contralateral Type IIIa Endoleak

We report the case of a 79-year-old man who was admitted to our department with acute limb ischemia due to the occlusion of the left iliac limb of an Endurant endograft. The admission computed tomography angiography revealed also a type IIIa endoleak due to modular disconnection of the iliac extensions from the right iliac limb of the endograft main body. Interestingly, during the 4-year post-endovascular aneurysm repair period, an increased kinking of the right limb has been observed leading to an almost cross-limb configuration of the limbs at the time of complications. To our knowledge, this is the first case in the literature of the simultaneous presence of limb thrombosis and late type IIIa endoleak with this particular device. The ischemia was treated with a femoro-femoral cross-over bypass, and the endoleak was corrected with the position of 2 Endurant iliac limb extensions bridging the dislocated endograft pieces.

Endovascular Management of Type I Endoleak with Fenestrated Aortic "Cuff" and Afterwards Treatment of Endoleak Type III

Endovascular aortic repair (EVAR) has become preferable treatment of abdominal aortic aneurysms because of proven mortality reduction as well as complications reduction compared with open surgery. Endoleak remains a primary complication of EVAR, however, and occurs in 20 to 25% of the patients. EVAR patients thus undergo lifelong surveillance for the presence of aneurysm expansion and endoleaks usually via computed tomographic angiography. We describe the endovascular management of an enlarged aneurysmal sac size 3 years after EVAR due to combined endoleak of types 1 and 3. We needed to use a fenestrated aortic cuff, a main body graft extension, and an aortouniiliac converter device to seal the leak. This case highlights the potential challenges in identifying and treating type III endoleaks.

Delayed Type IIIb endoleak secondary to graft fabric tear 7 years following implantation of a Medtronic Talent endovascular aortic device: A case report and review of the literature

Objectives:

To report a rare case of delayed Type IIIb endoleak secondary to fabric tear following implantation of a Medtronic Talent endovascular device.

Methods:

A 83-year old gentleman underwent elective endovascular aneurysm repair for infrarenal abdominal aortic aneurysm with a Medtronic bifurcated stent graft in 2008.

Results:

Seven years after the initial repair, imaging surveillance revealed significant endoleak and brisk aneurysm sac expansion due to Type IIIb endoleak secondary to endograft limb fabric tear.

Conclusions:

This case illustrates the imperative role of imaging surveillance in detection of long-term endovascular aneurysm repair complications. Furthermore, we discuss exclusion of the graft tear with aortouniiliac stent grafting as the treatment for this complication.

Late Type 3b Endoleak with an Endurant Endograft

Endovascular stent grafting with different commercially available stent graft systems is widely applied for the treatment of abdominal aortic aneurysms with high success rates in the current era. Various types of endoleaks are potential complications of the procedure. They usually occur in the early period. In this report, we present type 3b endoleak occurring 14 months after a successful endovascular abdominal aortic aneurysm repair with a Medtronic Endurant stent graft.

Type IIIb Endoleak With the Endurant Stent-Graft

Purpose: To report 2 cases of type IIIb endoleak with the Endurant stent-graft and postulate the cause for the events. Case Report: A type IIIb endoleak was diagnosed at open conversion for a ruptured aneurysm 4 years after implantation of an Endurant stent-graft. In the other case, the endoleak was diagnosed at angiography 4 years after the Endurant stent-graft was implanted; the stent-graft was relined. In both cases the fabric hole was in the body of the stent-graft at the level of the top of the contralateral limb. Conclusion: The cause of the type IIIb endoleaks in these cases was fabric erosion likely due to interaction between the bare metal at the top of the contralateral limb and the fabric of the stent-graft body.

Stent fabric fatigue of grafts supported by Z-stents versus ringed stents: An in vitro buckling test

Stent-grafts externally fitted with a Z-shaped stents were compared to devices fitted with ringed stents in an in vitro oscillating fatigue machine at 200 cycles per minute and a pressure of 360 mmHg for scheduled durations of up to 1 week. The devices fitted with Z-stents showed a considerably lower endurance limit to buckling compared to the controls. The contact between the apexes of adjacent Z-stents resulted in significant damage to the textile scaffolds and polyester fibers due to the sharp angle of the Z-stents. The ringed stents did not cause any fraying in the textile scaffolds.