Diagnosis and treatment of a patient with type IV endoleak as a late complication after endovascular aneurysm repair

Diagnosis of Type IV Endoleak After Endovascular Aneurysm Repair Using Visualization With Novel Software

A Type IV endoleak is a very rare complication following endovascular aneurysm repair (EVAR) and differential diagnosis can be difficult. Reported here is a case that showed the development of a Type IV endoleak after an EVAR procedure, for which a novel software was useful to differentiate that from Type I based on visual confirmation. The 89-year-old man was diagnosed with a large abdominal aortic aneurysm, sized 70 mm, as shown by computed tomography (CT). EVAR was performed in a routine fashion using an Endurant II stent graft. Postoperative CT revealed a massive endoleak around the neck that was difficult to differentiate between Types I and IV. The use of the novel software Viewtify (SCIEMENT, Inc., Tokyo, Japan) to visualize the endoleak with surrounding tissues as real-time three-dimensional computer graphics (3DCG) resulted in confirmation that the endoleak was not from the proximal end but rather the stent graft body. CT findings obtained one week later showed that the endoleak had diminished and no additional procedures were needed. Following a diagnosis of endoleak after EVAR, images viewed with Viewtify helped to confirm the appropriate diagnosis. This novel software was found useful to clarify the position and mechanism of a Type IV endoleak.

[Endoleaks in endovacular infrarenal abdominal aortic aneurysm repair. (Part II)]

Searching for literature data was performed in the PubMed, Scopus and eLIBRARY databases. In the second part, we considered modern classifications of endoleaks type 3, 4 and 5 after endovascular infrarenal abdominal aortic aneurysm repair, etiology, risk factors, classification of endoleaks. Modern data on effectiveness of their treatment by various methods are presented.

Late type III endoleak after thoracic endovascular aneurysm repair and previous infrarenal stent graft implantation - a case report and review of the literature

Thoracic endovascular aortic repair (TEVAR) effectively improved the results of thoracic aortic aneurysm treatment. TEVAR is a less invasive procedure that can be performed under local anesthesia with shorter hospital stay. The perioperative morbidity and mortality rates are lower for endovascular than open repair, but the rate of secondary interventions is higher for TEVAR. We report a case of an elderly man with synchronous abdominal and thoracic aortic aneurysms. A type III dangerous endoleak was recognized 3 years after TEVAR. It was successfully repaired during an endovascular procedure. There were no new endoleaks after 12 months of follow-up. TEVAR may be the only option of treatment for risky and elderly patients. However, postoperative monitoring is necessary to exclude different types of endoleaks. Most of them undergo effective endovascular repair.

Late Sac Rupture due to a Type IV Endoleak after Previous Endovascular Aortic Aneurysm Repair: A Case Report

Type IV endoleaks have been identified as endoleaks of low flow, and rupture risk has been estimated to be minimal in literature. Therefore, conservative treatment has been recommended in most cases. We are presenting a rare case of late rupture due to type IV endoleak that was treated with open repair applying a novel surgical technique.

An unusual case of aortic rupture after deployment of a bare stent in the treatment of aortic dissection in a patient with giant-cell arteritis

Giant-cell arteritis is associated with a higher risk of aortic aneurysm and aortic dissection formation. We present a women with aortic dissection type B treated with a stent graft and bare-metal stent implantation. After the stent deployment we noticed aortic rupture, which was successfully treated with implantation of an additional stent graft. This report highlights the difficulty of endovascular therapy in patients with giant-cell arteritis. We have to bear in mind that chronic inflammation of the aorta leads to a more fragile aortic wall than normal. We recommend the use of a stent graft over a bare-metal stent and gentle use of a balloon catheter.

Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx

Introduction

Type 2 endoleaks (T2E) occur in 10 to 20% of patients after endovascular abdominal aortic aneurysm repair (EVAR) and remain a significant clinical issue.

Aim

To evaluate the efficacy and clinical outcomes of transarterial treatment of persistent type II endoleaks after EVAR using the liquid embolic Onyx.

Material and methods

From February 2012 to August 2015 transarterial T2E embolization was attempted in 22 patients (21 men, median age: 73, range: 62–88 years). Indications for treatment included an increase in the diameter of the aneurysm sac above 5 mm and a persistent endoleak observed for more than 6 months. Mean time from EVAR to endoleak treatment was 43 months (range: 2–125 months).

Results

Primary technical success was achieved in 17 (77.3%) patients and secondary technical success in 81.8%, with 0% in-hospital mortality. The mean procedure time was 95 ±48 min, with an average fluoroscopy time of 54 ±25 min. The mean amount of Onyx used was 7.5 ±6.6 ml. Clinical success was seen in 17/21 patients with follow-up imaging (80.9%). Mean follow-up time was 17 months (range: 3–38 months).

Conclusions

Onyx has been shown to effectively stabilize previous aneurysm growth as a result of the T2E in the majority of our patients. Transarterial embolization of T2E can be significantly improved as compared to previously reported results by using liquid embolic polymers such as Onyx.

Limb volume measurements: comparison of accuracy and decisive parameters of the most used present methods

Limb volume measurements are used for evaluating growth of muscle mass and effectivity of strength training. Beside sport sciences, it is used e.g. for detection of oedemas, lymphedemas or carcinomas or for examinations of muscle atrophy. There are several commonly used methods, but there is a lack of clear comparison, which shows their advantages and limits. The accuracy of each method is uncertainly estimated only. The aim of this paper is to determine and experimentally verify their accuracy and compare them among each other. Water Displacement Method (WD), three methods based on circumferential measures—Frustum Sign Model (FSM), Disc Model (DM), Partial Frustum Model (PFM) and two 3D scan based methods Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) were compared. Precise reference cylinders and limbs of two human subjects were measured 10 times by each method. Personal dependency of methods was also tested by measuring 10 times the same object by 3 different people. Accuracies: WD 0.3 %, FSM 2–8 % according person, DM, PFM 1–8 %, MRI 2 % (hand) or 8 % (finger), CT 0.5 % (hand) or 2 % (finger);times: FSM 1 min, CT 7 min, WD, DM, PFM 15 min, MRI 19 min; and more. WD was found as the best method for most of uses with best accuracy. The CT disposes with almost the same accuracy and allows measurements of specific regions (e.g. particular muscles), as same as MRI, which accuracy is worse though, but it is not harmful. Frustum Sign Model is usable for very fast estimation of limb volume, but with lower accuracy, Disc Model and Partial Frustum Model is useful in cases when Water Displacement cannot be used.

All dangerous types of endoleaks after endovascular aneurysm repair in a single patient

Endovascular aneurysm repair (EVAR) has become tremendously popular in recent years. However, the long-term results of these stent grafts are uncertain and are still being evaluated. According to some data, the graft-related complication rate after EVAR could be as high as 43% in long-term observation. In this case report, we present a patient who had all dangerous types of endoleaks after EVAR and required sophisticated management including endovascular and open surgical repairs. After repeated invasive treatment, it was possible to exclude all endoleaks, and now the patient is free from graft-related complications. Although EVAR has become very popular, we should remember about possible complications, which could be very severe and life-threatening. For this reason, the choice between endovascular and open repair of abdominal aortic aneurysm should be well considered.