Parallel placement of Excluder legs for treatment of type IIIb endoleaks caused by fabric tear after endovascular aneurysm repair

Relining of infrarenal stent-graft with preloaded modified Gore Excluder for occult endoleak with sac expansion

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.

Parallel Placement of Excluder Legs to Treat Abdominal Aortic Aneurysms with Aortoiliac Occlusive Lesion

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.

Parallel Placement of Excluder Legs for the Treatment of a Type IIIb Endoleak Using AFX2

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.

Evolving concepts and management of endoleaks after endovascular aneurysm repair: where do we stand in 2019?

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.

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.

Surgery for a Late Type IIIb Endoleak From a Fabric Tear of an Excluder Stent Graft

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.

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.