Natural history of gutter-related type Ia endoleaks after snorkel/chimney endovascular aneurysm repair

Abstract

Objective Alternative endovascular strategies utilizing parallel or snorkel/chimney (ch-EVAR) techniques have been developed to address the lack of widespread availability and manufacturing limitations with branched/fenestrated aortic devices for the treatment of complex abdominal aortic aneurysms. Despite high technical success and mid-term patency of snorkel stent configurations, concerns remain regarding the perceived increased incidence of early gutter-related type Ia endoleaks. We aimed to evaluate the incidence and natural history of gutter-related type Ia endoleaks following ch-EVAR. Methods Review of medical records and available imaging studies, including completion angiography and serial computed tomographic angiography, was performed for all patients undergoing ch-EVAR at our institution between September 2009 and January 2015. Only procedures involving ≥1 renal artery with or without visceral snorkel stents were included. Primary outcomes of the study were presence and persistence or resolution of early gutter-related type Ia endoleak. Secondary outcomes included aneurysm sac shrinkage and need for secondary intervention related to the presence of type Ia gutter endoleak. Results Sixty patients (mean age, 75.8 ± 7.6 years; male, 70.0%) underwent ch-EVAR with a total of 111 snorkel stents (97 renal [33 bilateral renal], 12 SMA, 2 celiac). A median of 2 (range, 1-4) snorkel stents were placed per patient. Early gutter-related type Ia endoleaks were noted on 30.0% (n=18) of initial postoperative imaging studies. Follow-up imaging revealed spontaneous resolution of these gutter endoleaks in 47.3% and 71.8% of patients at 6- and 12 months post-procedure, respectively. Long-term anticoagulation, degree of oversizing, stent type and diameter, and other clinical/anatomic variables were not significantly associated with presence of gutter endoleaks. Two patients (3.3%) required secondary intervention related to persistent gutter endoleak. At a mean radiologic follow-up of 20.1 months, no difference in mean aneurysm sac size change was observed between those with or without early type Ia gutter endoleak (−6.1 ± 10.0-mm vs. −4.9 ± 11.5-mm, P=.23). Conclusions Gutter-related type Ia endoleaks represent a relatively frequent early occurrence after ch-EVAR, but appears to resolve spontaneously in the majority of cases during early to mid-term follow-up. Given that few ch-EVAR patients require re-intervention related to gutter endoleaks and the presence of such endoleak did not correlate to increased risk for aneurysm sac growth, its natural history may be more benign than originally expected.

Chimney grafts in renal arteries: a clinical model for coronary perfusion in future transcatheter aortic root repair techniques

“…Seventeen articles published in 2010-2017 were identified and reviewed [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. A total number of 430 patients (327-males; 93-females; 10-undisclosed) with mean age of 74.5 ± 2.9 years were treated for abdominal aorta disease using EVAR with renal CG.…”

Secondary Endoleak Management Following TEVAR and EVAR

“…Type 1a endoleaks are related to adverse proximal neck anatomy and there is an increased risk of these as more challenging [9,10]. Early EL1a is a common complication (30%) after snorkel/chimney EVAR technique, with high spontaneous resolution in up to 71.8% at 12 months and a low reintervention rate at 3.3% [11]. Late EL1a has been reported in up to 7% of patients after chimney EVAR [9].…”

Select early type IA endoleaks after endovascular aneurysm repair will resolve without secondary intervention

“…This is consistent with previous reports that have failed to show any reproducible predictors of either type IA endoleaks or their failure to resolve intraoperatively. [14][15][16][17][18][19][20][21] Bastos Gonçalves et al 8 reported that neck length and neck thrombus or calcifications predicted adverse neck events, whereas Tan et al 14 found that age, female gender, large main body graft diameter, and unplanned graft extension were the only predictive factors.…”