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

Abstract

).Endovascular aortic repair (EVAR) avoids the disadvantages of major surgery such as a large incision, full heparinization, extracorporeal circulation, aortic cross-clamping, interference with respiratory function, and the need for massive blood transfusions. Endoleak remains a primary complications of EVAR, however, and occurs in 20 to 25% of the patients.1,2 EVAR patients thus undergo lifelong surveillance for the presence of aneurysm expansion and endoleaks, usually via computed tomographic angiography (CTA). 2We describe the endovascular management of an enlarged aneurysmal sac 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. Case ReportA 75-year-old man with a 5.5 cm infrarenal aortic aneurysm was electively treated in 2008 with an endovascular talent stent graft (Medtronic, Minneapolis, MN) measuring 28 mm in diameter. The patient course was uncomplicated and the final angiography showed no endoleak. At 3 months followup, the size of the aneurysmal sac had increased by a few millimeters, suggesting a type II endoleak. The patient was conservatively managed and kept under observation and at 1 year follow-up the aneurysmal sac size was unchanged.The patient was then lost to follow-up for 2 years but in 2011 a contrast-enhanced CT scan and angiography revealed a type Ia endoleak and 2 cm increase in the aneurysmal sac size (►Fig. 1). The proximal landing zone was too short, especially on the left side where the aneurysm neck was only 5 mm long. The patient underwent endovascular treatment where a fenestrated custom-made aortic cuff with diameter of 30 Â 58 mm (Cook, Bloomington, IN) and two fenestrations for the renal artery and a scallop for the superior mesenteric artery was placed according to the standard guidelines. Advanta stent grafts (Atrium, Netherlands) of 6 Â 22 mm on the right side and 7 Â 22 mm on the left side were placed in the renal arteries using a left femoral route. The guide wire was placed in the superior mesenteric artery through the left brachial artery to allow rapid arterial access in the event of AbstractEndovascular 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 id...

Endovascular Repair for a Ruptured AAA due to a Combined Type IIIb and Ia Endoleak

“…Two days later, the patient was discharged. Finally, Duvnjak reported a case where there was a combination of type Ia and IIIb endoleaks two years after the placement of a Talent endograft in a 75-year-old man [ 14 ]. Initially, only the type Ia endoleak was managed, as the type IIIb endoleak was not easily apparent and it was underestimated in the first place.…”

“…Initially, only the type Ia endoleak was managed, as the type IIIb endoleak was not easily apparent and it was underestimated in the first place. For the first endoleak, a fenestrated custom-made aortic cuff (Cook, Bloomington, IN) was used, whereas for the latter type, one month later, an aortouniiliac converter device (Cook) was used, together with a femorofemoral bypass for perfusion of the opposite limb [ 14 ]. The unique feature of this case report is the coexistence of combined type Ia and IIIb endoleaks and the simultaneous treatment of both entities during the same session.…”

“…The unique feature of this case report is the coexistence of combined type Ia and IIIb endoleaks and the simultaneous treatment of both entities during the same session. It is a word of caution that the IIIb endoleak may be obscured or underestimated in the preoperative imaging and even during the intraoperative angiogram, like in Duvnjak case or in our case as well [ 14 ]. Moreover, the case shows an “off the shelves” solution to treat emergency situation like AAA rupture for similar cases, since special bifurcated endografts are lacking to be used as an “inlay” technique.…”

“…Although such cases have not been reported in the past, they might have been existed, but the most obvious type Ia endoleak might obscured the type IIIb endoleak, something that initially misled us as well. Combined endoleaks constitute a separate entity and should be approached in a different fashion, because sealing only one of them might not solve the whole problem after all as what happened in Duvnjak case [ 14 ]. In our case, if the fabric tear was not situated near the bifurcation but 2 cm proximally, the Ankura cuff would seal both endoleaks and the type IIIb endoleak would go undiagnosed.…”

Evolving Concepts, Management, and Treatment of Type 1 Endoleaks after Endovascular Aneurysm Repair

“…For patients who present with a T1a endoleak on subsequent imaging or caudal device migration overtime resulting in a reduced landing zone, a fenestrated endograft provides a solution for proximal extension. 45 In the United States, the commercially available endograft that can be employed for this purpose is the Cook Zenith aortic stent graft which was approved by the Food and Drug Administration in 2012 for endovascular treatment of shortneck infrarenal and juxtarenal aneurysms. 29 Up to three fenestration or scallops are incorporated into the main body to allow continued flow into the visceral vessels while permitting extension of the proximal landing zone from the infrarenal aorta to the paravisceral region.…”