Laparoscopic Inferior Mesenteric Artery Ligation: An Alternative for the Treatment of Type II Endoleaks

Understanding Type II Endoleak: A Harmless Imaging Finding or a Silent Threat?

Type II endoleak (T2EL) represents a challenging clinical entity following endovascular abdominal aortic aneurysm repair (EVAR). Although several studies have suggested that T2ELs are related to an increased risk of aneurysm sac growth and subsequent rupture, the exact role that T2ELs play in long-term outcomes remains debatable. Understanding the pathophysiology, diagnostic modalities, and management options of T2ELs is important for patients' safety and proper resource utilization. While conservative management may be suitable for asymptomatic patients with a stable aneurysm size, interventional approaches, including transarterial embolization, direct sac puncture embolization and open conversion have been described for patients with persistent T2EL associated with sac expansion. However, more research is needed to better determine the clinical benefit of such interventions. A thorough evaluation of all endoleak types before T2EL treatment would be reasonable for patients with T2ELs associated with sac expansion. Further studies are needed to refine treatment strategies aimed at minimizing T2EL-related complications. Collaborative efforts among vascular specialists, radiologists, and researchers are of paramount importance to address this ongoing clinical challenge.

Laparoscopic Ligation of the Inferior Mesenteric Artery: A Systematic Review of an Emerging Trend for Addressing Type II Endoleak Following Endovascular Aortic Aneurysm Repair

Background/Objectives: this systematic review aims to explore the efficacy and safety of the laparoscopic ligation of the inferior mesenteric artery (IMA) as an emerging trend for addressing a type II endoleak following endovascular aortic aneurysm repair (EVAR). Methods: A comprehensive literature search was conducted across several databases including Medline, Scopus, and the Cochrane Central Register of Controlled Trials, adhering to the PRISMA guidelines. The search focused on articles reporting on the laparoscopic ligation of the IMA for the treatment of a type II endoleak post-EVAR. Data were extracted regarding study characteristics, patient demographics, technical success rates, postoperative outcomes, and follow-up results. Results: Our analysis included ten case studies and two retrospective cohort studies, comprising a total of 26 patients who underwent a laparoscopic ligation of the IMA between 2000 and 2023. The mean age of the cohort was 72.3 years, with a male predominance (92.3%). The mean AAA diameter at the time of intervention was 69.7 mm. The technique demonstrated a high technical success rate of 92.3%, with a mean procedure time of 118.4 min and minimal blood loss. The average follow-up duration was 19.9 months, with 73% of patients experiencing regression of the aneurysmal sac, and no reports of an IMA-related type II endoleak during the follow-up period. Conclusions: The laparoscopic ligation of the IMA for a type II endoleak following EVAR presents a promising, minimally invasive alternative with high technical success rates and favorable postoperative outcomes. Despite its potential advantages, including reduced contrast agent use and radiation exposure, its application remains limited to specialized centers. The findings suggest the need for further research in larger prospective studies to validate the effectiveness of this procedure and potentially broaden its clinical adoption.

Laparoscopic lumbar artery ligation of type II endoleaks following endovascular aneurysm repair: A case report

INTRODUCTION

Although the clinical significance of type II endoleaks remain controversial, management strategies continue to expand. The laparoscopic approach is a minimally invasive method for persistent type II endoleak repair after endovascular aneurysm repair.

PATIENT CONCERNS

A 70 - year - old male patient with a history of endovascular aneurysm repair with left internal iliac artery embolization presented with persistent type II endoleak from the lumbar arteries 2 years ago. The aneurysm sac size had increased more than 10 mm during follow up period.

DIAGNOSIS

Persistent type II endoleak after endovascular aneurysm repair.

INTERVENTIONS

Transarterial embolization was attempted and failed. A minimally invasive laparoscopic lumbar artery ligation was then utilized.

OUTCOMES

The patient was discharged without any complications after surgery. Follow-up computed tomography angiography has shown the complete disappearance of the type II endoleaks.

CONCLUSIONS

Laparoscopic lumbar artery ligation may be a safe and effective alternative treatment for type II endoleaks, especially in high resource settings.

Laparoscopic Clipping of the Inferior Mesenteric Artery and Intraoperative Indocyanine Green Angiography for Type II Endoleak Following Endovascular Aneurysm Repair

Background: Type II endoleaks from a patent inferior mesenteric artery (IMA) occur in up to one-third of patients undergoing endovascular repair of abdominal aortic aneurysms. In the majority of patients, retrograde flow in the aneurysmal sac outside the endograft will seal over time and is rarely associated with sac enlargement or aortic rupture. Intervention is generally recommended in patients with progressively enlarging endoleaks, especially when the sac diameter increases >10 mm during the follow-up, and endovascular IMA embolization has a high rate of treatment failure. Methods: We report a procedure of laparoscopic IMA clipping combined with intraoperative indocyanine green (ICG) angiography to confirm vascular anatomy, colonic perfusion, and the technical success of the procedure. Results: Three selected octogenarian patients with persistent type II endoleak after endovascular repair of abdominal aortic aneurysm underwent IMA clipping with ICG angiography. Mean operative time was 58 ± 9 minutes. There were no procedure-related complications, and no hypersensitivity reactions nor other side effects associated with ICG dye administration occurred. All patients were discharged home on postoperative day 1 and are asymptomatic and free of recurrence at a mean follow-up of 15 months. Conclusions: Laparoscopic IMA clipping is a safe remedial procedure in patients with type II endoleak after endovascular repair of abdominal aortic aneurysms.

Total Laparoscopic Inferior Mesenteric Artery Ligation and Direct Sac Puncture Embolization Technique for Treatment of Type II Endoleak

Type II endoleak relates to aneurysm perfusion through a patent branch vessel. Reintervention for type II endoleak should be considered in the presence of significant aneurysm growth. Recurrences and subsequent reinterventions are frequent by occult type II endoleaks through feeder arterial branches. We report a case of a patient with a type II endoleak due to inferior mesenteric artery (IMA) patency associated with aneurysm sac growth after an unsuccessfully attempt of transarterial embolization. Laparoscopic ligation of the IMA with direct sac puncture embolization was performed. The postoperative and 1-year follow-up computed tomography angiography scan demonstrated no endoleak signs and aneurysm sac shrinkage. The proposed modification of this technique constitutes a novel approach to this entity. Total laparoscopic IMA ligation and direct sac puncture embolization technique may increase the success rate for the treatment of endoleaks type II by excluding the recurrences. This technique may offer a safe, feasible, and minimally invasive approach for type II endoleaks when other endovascular techniques are unsuccessful.

Laparoscopic ligation of Type II endoleaks following endovascular aneurysm repair: A systematic review

INTRODUCTION

The clinical significance of Type II endoleak remains contentious; the strategies used for its management have continued to expand. We systematically review the literature and comprehensively appraise the effectiveness of laparoscopic intervention in the management of this common complication.

METHODS

A systematic search was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines on MEDLINE, EMBASE and Cochrane Library for relevant articles reporting laparoscopic surgery of Type II endoleak post-endovascular aortic repair.

RESULTS

Thirteen studies representing 40 patients were investigated. Mean age was 72.7 years, and proportion of males was 90.0%. All patients were American Society of Anesthesiologists grade II and above and underwent standard infrarenal endovascular aneurysm repair. The mean duration of operation was 130.2 min, with a mean blood loss across of 173.8 mL. The overall technical success rate was 90% (27/30). Two patients required reoperation within 24 h, with further lumbar ligations that were successful. One other patient required conversion to open surgery due to significant bleeding at the dorsal aorta. The perioperative and 30-day mortality rate was 2.5% (1/40). The mean length of hospital stay was 3.7 days (range 1 to 10 days). The mean length of follow-up was 36.7 months (range 3 to 103.2 months), where the rate of recurrence was 22.5% (9/40).

CONCLUSIONS

Laparoscopic ligation of feeding vessels causing Type II endoleak is potentially an alternative treatment after failed standard endovascular embolization, particularly in select centres with necessary resources and capabilities.

Editor's Choice - Systematic Review and Meta-Analysis of the Outcome of Treatment for Type II Endoleak Following Endovascular Aneurysm Repair

OBJECTIVES

The efficacy and need for secondary interventions for type II endoleaks following endovascular abdominal aortic aneurysm repair (EVAR) remain controversial. This systematic review aimed at investigating the clinical outcomes of different type II endoleak treatments in patients with a persistent type II endoleak after EVAR.

DATA SOURCES

Embase, Medline via Ovid, Web of Science Core Collection, the Cochrane CENTRAL, and Google Scholar.

REVIEW METHODS

This systematic review was performed in accordance with the PRISMA Statement. Outcomes of interest were technical and clinical success, change in sac diameter, complications, need for additional interventions, abdominal aortic aneurysm (AAA) rupture, and (AAA related) mortality. Meta-analyses were performed with random effects models.

RESULTS

A total of 59 studies were included, with a cumulative cohort of 1073 patients with persistent type II endoleak. Peri-operative complications following treatment of type II endoleaks occurred in 3.8% of patients (95% CI 2.7-5.2%), and AAA related mortality was 1.8% (95% CI 1.1-2.7%). Overall technical success was 87.9% (95% CI 83.1-92.1%), while clinical success was 68.4% (95% CI 61.2-75.1%). Among studies detailing sac dynamics, decrease or stable sac, with or without resolution, was achieved in 78.4% (95% CI 70.2-85.6%). Changes in sac diameter following type II endoleak treatment were documented in 157 patients to at least 24 months. Within this group an actual decrease in sac diameter was reported in only 27 of 40 patients.

CONCLUSION

There is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although generally safe, the lack of evidence supporting the efficacy of type II endoleak treatment leads to difficulty in assessing its merits.

Systematic review of laparoscopic ligation of inferior mesenteric artery for the treatment of type II endoleak after endovascular aortic aneurysm repair

OBJECTIVE

Type II endoleak after endovascular aneurysm repair (EVAR) is frequently caused by persistent flow from the inferior mesenteric artery (IMA). The aim of this study was to assess the perioperative and midterm efficacy of laparoscopic ligation of the IMA for treatment of endoleak.

METHODS

MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane databases and key references were searched with Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for studies reporting on laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR.

RESULTS

Eight case studies and one study of a retrospective nature were identified. In total, 20 patients (18 men; mean age, 73.6 ± 2 years; with a mean abdominal aortic aneurysm diameter of 64.3 ± 10 mm) who underwent post-EVAR laparoscopic ligation of the IMA for type II endoleak were analyzed. The mean time from EVAR until intervention ranged from 6 to 18 months. All but one patient were asymptomatic; in 9, the aneurysm sac was enlarged, and in 11, the endoleak was considered persistent without sac enlargement. The mean procedural duration was 99 ± 24 minutes, with technical success rate of 90% (18/20); in two cases, the patients were successfully reoperated on laparoscopically in 24 hours. The mean hospitalization was 3.6 ± 1.2 days, with 0% (0/20) perioperative and 30-day mortality. No patient underwent open conversion or showed signs of intestinal ischemia. During follow-up of 32.6 ± 12 months, 13 of 20 patients had aneurysm sac regression, whereas the rest had a stable sac diameter without evidence of persistent type II endoleak.

CONCLUSIONS

Laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR is a feasible and safe technique in specialized centers with high technical success rate and good midterm outcomes.

Type II endoleaks: challenges and solutions

Type II endoleaks are the most common endovascular complications of endovascular abdominal aortic aneurysm repair (EVAR); however, there has been a divided opinion regarding their significance in EVAR. Some advocate a conservative approach unless there is clear evidence of sac expansion, while others maintain early intervention is best to prevent adverse late outcomes such as rupture. There is a lack of level-one evidence in this challenging group of patients, and due to a low event rate of complications, large numbers of patients would be required in well-designed trials to fully understand the natural history of type II endoleak. This review will discuss the imaging, management, and outcome of patients with isolated type II endoleaks following infra-renal EVAR.

Type 2 Endoleaks Post-EVAR: Current Evidence for Rupture Risk, Intervention and Outcomes of Treatment

Type 2 endoleaks (EL2) are the most commonly encountered endoleaks following EVAR. Despite two decades of experience, there remains considerable variation in the management of EL2 with controversies ranging from if to treat, when to treat and how to treat. Here, we summarise the available evidence, describe the treatment techniques available and offer guidelines for management.

Type II endoleak after endovascular aneurysm repair

Background

The aim was to assess the risk of rupture, and determine the benefits of intervention for the treatment of type II endoleak after endovascular abdominal aortic aneurysm repair (EVAR).

Methods

This systematic review was done according to PRISMA guidelines. Outcome data included incidence, spontaneous resolution, sac expansion, interventions, clinical success, and complications including conversion to open repair, and rupture.

Results

Thirty-two non-randomized retrospective studies were included, totalling 21 744 patients who underwent EVAR. There were 1515 type II endoleaks and 393 interventions. Type II endoleak was seen in 10·2 per cent of patients after EVAR; 35·4 per cent resolved spontaneously. Fourteen patients (0·9 per cent) with isolated type II endoleak had ruptured abdominal aortic aneurysm; six of these did not have known aneurysm sac expansion. Of 393 interventions for type II endoleak, 28·5 per cent were unsuccessful. Translumbar embolization had a higher clinical success rate than transarterial embolization (81 versus 62·5 per cent respectively; P = 0·024) and fewer recurrent endoleaks were reported (19 versus 35·8 per cent; P = 0·036). Transarterial embolization also had a higher rate of complications (9·2 per cent versus none; P = 0·043).

Conclusion

Aortic aneurysm rupture after EVAR secondary to an isolated type II endoleak is rare (less than 1 per cent), but over a third occur in the absence of sac expansion. Translumbar embolization had a higher success rate with a lower risk of complications.

Quality improvement guidelines for imaging detection and treatment of endoleaks following endovascular aneurysm repair (EVAR)

Major concerns after aortic aneurysm repair are caused by the presence of endoleaks, which are defined as persistent perigraft flow within the aortic aneurysm sac. Diagnosis of endoleaks can be performed with various imaging modalities, and indications for treatment are based on further subclassifications. Early detection and correct classification of endoleaks are crucial for planning patient management. The vast majority of endoleaks can be treated successfully by interventional means. Guidelines for Imaging Detection and Treatment of endoleaks are described in this article.

Prevention of type II endoleak by laparoscopic inferior mesenteric artery ligation

Abdominal aortic aneurysm repair by endovascular techniques have gained wide acceptance as a treatment option. A potential well-known complication of endovascular repair includes endoleak. Specifically, type II endoleak, which is described as retrograde flow into the aneurysm sac through collateral vessels, can occur in up to 30% of patients. Certain preoperative factors can predict which patients may develop type II endoleak. This article describes laparoscopic inferior mesenteric artery ligation prior to endovascular abdominal aortic aneurysm repair as a viable treatment option in the prevention of type II endoleak.

Endovascular management of the patent inferior mesenteric artery in two cases of uncontrolled type II endoleak after endovascular aneurysm repair

Context:

Endovascular aneurysm repair (EVAR) has well documented advantages over traditional open repair and has been widely adopted as the alternative treatment modality for abdominal aortic aneurysm. However, endoleaks specifically type II can be a significant problem with this technique leading to aortic sac expansion and potential rupture. A large number of type II endoleaks are caused by persistent inferior mesenteric artery (IMA) retrograde bleeding. Various methods to try to manage this complication have been previously described. IMA embolization via the marginal artery of Drummond, however, has not been adequately popularized as an alternative less invasive approach to the treatment of type II endoleak.

Case Report:

Two men, ages 77 and 81, underwent uneventful EVAR for 5.5 and 5.0 cm infrarenal abdominal aortic aneurysms, respectively, using Zenith Cook^® bifurcated stent grafts. Computed tomography angiography at 1 and 6 months postoperatively demonstrated small type II endoleaks in both cases which were followed clinically. Subsequent follow-up tomography scan at 12 months revealed persistent type II endoleaks related to retrograde filling from the IMA with significant enlargement of the aneurysm sacs. Both patients underwent successful IMA coil embolization via the marginal artery of Drummond.

Conclusions:

Percutaneous IMA embolization using standard endovascular techniques to access the marginal artery of Drummond is an alternative, and in our opinion, preferred technique for controlling type II endoleaks caused by a persistently patent IMA.

Endoscopic type 2 endoleak repair following endovascular aortic aneurysm repair: acute results and follow-up experience

The purpose of this study was to evaluate immediate and long-term results of endoscopic type 2 endoleak repair (EER) following endovascular abdominal aortic aneurysm repair. The basic methods include a retrospective review of electronic and paper medical records of patients admitted or referred to our institution for EER. Between July 1999 and October 2007, eight consecutive patients underwent EER. Mean operative time was 190 (104–355) min. One patient died preoperatively, due to profuse venous bleeding . One procedure was redone due to a missed pair of lumbar arteries. Mean hospital stay was five days (2–10). During mean follow-up, 50 months (29–91), one patient required additional coil embolization for a persistent type 2 endoleak. Four patients were diagnosed with a type 1 and one with a type 3 endoleak; three of these patients required an additional procedure. In conclusion, in this small series EER proved not to be beneficial.

In vitro assessment of aortic stent-graft integrity following exposure to Onyx liquid embolic agent

PURPOSE

Endovascular stent-grafts are increasingly being used for treatment of abdominal and thoracic aortic aneurysms. Postprocedural complications include development of endoleaks. Recently, an embolic agent known as Onyx has been employed to treat type II endoleaks. Onyx is a biocompatible copolymer dissolved in dimethyl sulfoxide (DMSO). Although DMSO is known to damage some angiographic catheters, little is known concerning whether this compound damages stent-graft material. The current study was undertaken to directly explore this issue.

MATERIALS AND METHODS

Four stent-grafts were evaluated: the Excluder, Zenith, AneuRx, and Talent. Stent-grafts were incubated for 24 hours at 37 degrees C under each of the following conditions: DMSO alone, 50/50 mixture of DMSO/Onyx, mixture of 1 part 50/50 DMSO/Onyx and 9 parts whole blood, and untreated control. Stent-grafts were microdissected into 15-mm sections, after which they were evaluated with scanning electron microscopy.

RESULTS

No appreciable differences between stent-grafts exposed to DMSO and untreated controls were seen. Although liquid embolic agent was seen coating stent-grafts exposed to a 50/50 mixture of DMSO and Onyx, no evidence of fiber breakdown was noted. Stent-grafts exposed to DMSO/Onyx/whole blood demonstrated a thin coating of clot and Onyx without visual evidence of fiber compromise.

CONCLUSIONS

The current study provides compelling evidence that short-term exposure of endograft material to DMSO, DMSO/Onyx, or DMSO/Onyx/whole blood is not associated with acute structural compromise of four commonly used aortic endografts. Future in vivo studies will help to further establish the safety of this agent.

Treatment of a Large Type II Endoleak via Extraperitoneal Dissection and Embolization of a Collateral Vessel Using Ethylene Vinyl Alcohol Copolymer (Onyx)

Type II endoleak is defined as persistent blood flow and pressure within an aneurysmal sac after endovascular deployment of a stent graft from patent aortic branches. This paper describes the simultaneous deployment of an endoluminal graft, with limited extraperitoneal dissection of a collateral vessel and use of an ethylene vinyl alcohol copolymer, Onyx, to obliterate a large type II endoleak.

Percutaneous protective coil occlusion of the proximal inferior mesenteric artery before N-butyl cyanoacrylate embolization of type II endoleaks after endovascular repair of abdominal aortic aneurysms

Bowel ischemia can complicate treatment of type II endoleak with liquid or semiliquid agents such as n-butyl cyanoacrylate (NBCA) if nontarget embolization of the inferior mesenteric artery (IMA) occurs. The current report describes four cases of type II endoleak in which the IMA was the main outflow vessel and was prophylactically occluded with embolization coils before NBCA injection into the endoleak nidus. The purpose was to prevent unintentional embolization of the NBCA into IMA branches. If feasible, protective IMA coil occlusion should be considered in type II endoleaks with IMA outflow in cases of NBCA embolization.

IMA Clipping for a Type II Endoleak

We describe herein a combined laparoscopic and endovascular approach to treat a type II endoleak due to retrograde flow in the patent inferior mesenteric artery (IMA). A 61-year-old gentleman presented with enlarging aneurysm sac confirmed on computed tomography scan evaluation after elective endovascular repair of an infrarenal abdominal aortic aneurysm. A combined laparoscopic and endovascular approach was used. After distal IMA was identified and marked with a clip laparoscopically, on-table angiography showed a proximal left colic branch and persistent flow in the IMA. Therefore, further laparoscopic exploration was performed by dissection along the distal branch. The origin of IMA was then located and subsequently sealed with 2 surgical clips. The completion angiography confirmed the proper position of the surgical clips and absence of endoleak. Our case demonstrated useful role of endovascular techniques in identifying the origin of IMA during laparoscopic approach for treating type II endoleak.

Endoleakage after endovascular treatment of abdominal aortic aneurysms: diagnosis, significance and treatment

Endoleak, also called leakage, leak and Perigraft leak, is a major complication and its persistence represents a failure of endovascular aortic aneurysm repair. Its detection and treatment is therefore of primary importance, since endoleak can be associated with pressurization (increase in pressure) of the sac, resulting in expansion and rupture of the aneurysm. The aim of this paper is to discuss the definition, significance, diagnosis and different options to treat endoleak.