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Mirza AK, Skeik N, Manunga J. Relining of infrarenal stent-graft with preloaded modified Gore Excluder for occult endoleak with sac expansion. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:669-674. [PMID: 34693100 PMCID: PMC8515168 DOI: 10.1016/j.jvscit.2021.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/10/2021] [Indexed: 11/29/2022]
Abstract
Endoleaks remain one of the most common indications for reintervention after endovascular aortic repair. Occasionally, aneurysm sac expansion will occur in the absence of a visible endoleak or due to endotension. We describe a case of continued sac expansion without an identifiable endoleak after endovascular aortic repair. Technical challenges during the case included a short distance from the renal arteries to the flow divider and a significant metal artifact. These challenges were addressed by shortening the gate of a Gore Excluder (W.L. Gore & Associates, Flagstaff, Ariz) to the desired length. The contralateral gate was preloaded to allow for use of the snare-ride technique for gate cannulation and overcome the metal artifact that was hindering visualization.
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Affiliation(s)
- Aleem K Mirza
- Division of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Nedaa Skeik
- Division of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Jesse Manunga
- Division of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
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Kato H, Kato N, Nakajima K, Higashigawa T, Ouchi T, Chino S, Tokui T, Sakuma H. Parallel Placement of Excluder Legs to Treat Abdominal Aortic Aneurysms with Aortoiliac Occlusive Lesion. Ann Vasc Dis 2020; 13:319-321. [PMID: 33384738 PMCID: PMC7751086 DOI: 10.3400/avd.cr.20-00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The effectiveness of endovascular aneurysm repair (EVAR) has been proven, but anatomical limitations, including narrow access route, may obstruct procedure of EVAR and cause serious complications. Parallel placement of Excluder legs (W. L. Gore & Associates, Inc., Newark, DE, USA) was established to treat patients with type IIIb endoleak or those with a narrow aorta, who could not be treated using a standard main body. In this report, we applied this technique in two patients with aortoiliac aneurysms with occlusive lesion.
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Affiliation(s)
- Hiroaki Kato
- Department of Radiology, Mie University Hospital
| | | | | | | | | | - Shuji Chino
- Department of Radiology, Ise Red Cross Hospital
| | - Toshiya Tokui
- Department of Cardiovascular Surgery, Ise Red Cross Hospital
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Kato H, Kato N, Nakajima K, Higashigawa T, Ouchi T, Chino S, Sakuma H. Parallel Placement of Excluder Legs for the Treatment of a Type IIIb Endoleak Using AFX2. Ann Vasc Dis 2020; 13:180-182. [PMID: 32595796 PMCID: PMC7315243 DOI: 10.3400/avd.cr.19-00110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Endoleak is a major complication of endovascular aneurysm repair (EVAR). Type IIIb endoleaks, which are caused by endograft fabric disruption, are relatively rare. Although relining of the previously placed endograft with another main endograft is considered an ideal approach, it is sometimes difficult. The efficacy of parallel placement of Excluder legs has been reported in various settings. Here, we report the successful treatment of a type IIIb endoleak with parallel placement of Excluder legs during EVAR by using an AFX2 device.
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Affiliation(s)
- Hiroaki Kato
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Noriyuki Kato
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Ken Nakajima
- Department of Radiology, Ise Red Cross Hospital, Ise, Mie, Japan
| | | | - Takafumi Ouchi
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Shuji Chino
- Department of Radiology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Hajime Sakuma
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
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Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair. J Vasc Surg 2020; 71:645-653. [DOI: 10.1016/j.jvs.2019.06.183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 06/28/2019] [Indexed: 11/18/2022]
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Cannavale A, Lucatelli P, Corona M, Nardis P, Basilico F, De Rubeis G, Santoni M, Catalano C, Bezzi M. Evolving concepts and management of endoleaks after endovascular aneurysm repair: where do we stand in 2019? Clin Radiol 2019; 75:169-178. [PMID: 31810539 DOI: 10.1016/j.crad.2019.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/31/2019] [Indexed: 11/27/2022]
Abstract
In recent years, there has been tremendous progress in endovascular aneurysm repair (EVAR) techniques and devices. This process has seen a change in incidence, risk factors, and treatment of endoleaks as well as in follow-up protocols after EVAR. In particular, recent literature has highlighted new concepts in the evaluation and prevention/treatment of type I and II endoleak after standard EVAR. There is also recent evidence regarding new imaging protocols for follow-up after EVAR, which include magnetic resonance imaging and contrast-enhanced ultrasound. This comprehensive review aims to outline the most recent concepts on imaging follow-up, pathophysiology/risk factors, and management of endoleaks.
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Affiliation(s)
- A Cannavale
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
| | - P Lucatelli
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - M Corona
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - P Nardis
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - F Basilico
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - G De Rubeis
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - M Santoni
- Department of Radiological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - C Catalano
- Department of Radiological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Bezzi
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
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Nishibe T, Iwahashi T, Kamiya K, Kano M, Maruno K, Koizumi J, Dardik A, Ogino H. Type IIIb Endoleak After Endovascular Aneurysm Repair Using the Zenith Stent Graft. Vasc Endovascular Surg 2019; 53:515-519. [PMID: 31238816 DOI: 10.1177/1538574419858824] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Toshiya Nishibe
- 1 Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Toru Iwahashi
- 1 Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Kamiya
- 1 Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masaki Kano
- 1 Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Keita Maruno
- 1 Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Jun Koizumi
- 2 Department of Diagnostic Radiology, Tokai University School of Medicine, Isehara, Japan
| | - Alan Dardik
- 3 Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Hitoshi Ogino
- 1 Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
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Surgery for a Late Type IIIb Endoleak From a Fabric Tear of an Excluder Stent Graft. Ann Vasc Surg 2019; 59:309.e1-309.e4. [PMID: 30802563 DOI: 10.1016/j.avsg.2018.12.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 12/05/2018] [Accepted: 12/16/2018] [Indexed: 11/22/2022]
Abstract
An 85-year-old male patient, who had undergone endovascular abdominal aortic aneurysm repair (EVAR) using the Gore Excluder stent graft 10 years ago, was referred for intermittent abdominal pain. He also received coil embolization of the lumbar arteries for a persistent type II endoleak, resulting in continued aneurysmal dilation at 4, 6, and 8 years after the EVAR. The maximum size of the aneurysm sac was dilated from the initial size of 49 mm × 55 mm to 78 mm × 90 mm, and the contrast medium was observed around the proximal portion of the stent graft, suggesting the presence of a type Ia or II endoleak. Because the definite cause of the dilation was unclear and adequate proximal landing zone was not available to deploy an aortic cuff, emergent laparotomy was indicated to treat this symptomatic aneurysm dilation. A type IIIb endoleak due to fabric disruption of the main body was diagnosed, and the bleeding was controlled using a fibrin sealant patch. To reinforce the hemostasis site from the inside of the stent graft, a 28 mm × 3-cm Excluder aortic cuff was deployed inside the main trunk next day. At 1-year follow-up, his condition was stable without evidence of reexpansion of the aneurysmal sac.
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Lowe C, Hansrani V, Madan M, Antoniou GA. Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 61:308-316. [PMID: 29616524 DOI: 10.23736/s0021-9509.18.10446-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Christopher Lowe
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK -
| | - Vivak Hansrani
- Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Manmohan Madan
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
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