Open Surgical Repair Can Be One Option for the Treatment of Persistent Type II Endoleak after EVAR

Abstract

Purposes: Endovascular abdominal aortic aneurysm repair (EVAR) is an increasingly used method of repairing abdominal aortic aneurysm (AAA). However, the treatment of persistent type II endoleak is still a controversial issue. Five cases are reported here in which we performed open surgical repair of growing aneurysm due to persistent type II endoleak. Method: Totally 128 EVAR cases were retrospectively reviewed, which were operated in our hospital from April 2008 to October 2013. These cases were followed by periodical contrast-enhanced computed tomography (CT) after EVAR. When persistent type II endoleak caused aneurysm sac growth, we performed surgical repair method for the first line treatment. In the operation, we incised the aneurysm sac by abdominal small median incision approach and sutured lumber arteries from inside of aneurysm sac and tied inferior mesenteric artery (IMA) in addition to aneurysmorrhaphy. Contrast-enhanced CT scanning was performed in a week after open repair for the confirmation of complete treatment. Results: Five of 128 cases (3.9%) were needed to be surgically repaired because of aneurysm sac growth (>5 mm), including two ruptured AAA cases. All patients recovered uneventfully. Contrast-enhanced CT scanning performed a week after these operations showed no endoleak and intact stent grafts and reduction of the aneurysm size. Conclusion:We believe open surgical repair method of persistent type II endoleak with aneurysm expansion is secure method, and can be one of the preferable options for this life threatening complication after EVAR.Keywords: EVAR, AAA, type II endoleak, surgical repair less invasive method of abdominal aortic aneurysm (AAA) repair continues to gain popularity. Studies that compared the outcome of EVAR with open graft replacement have consistently demonstrated a significant reduction in morbidity with endovascular repair. [1][2][3][4] However, new type complications have plagued the stent graft approach, and importantly the failure to totally exclude the AAA by persistent perfusion and pressurization, defined as endoleak is one of the adverse outcomes. 5,6) Despite consensus on the treatment of type I and type III endoleak, controversy remains about the optimal strategy for the treatment of type II endoleak because each strategy has their own advantages and disadvantages. Although previous studies have shown that most type II endoleaks are benign and are rarely associated with adverse of events, 7) there are increasing reports of expanding aneurysm in the presence of type II endoleak eventually leading to aneurysm rupture. 8,9) A variety of treatment or prevention methods have been advocated. These days, the most popular approach for the treatment of type II endoleak is transarterial coil embolization or translumber embolization. Transarterial or translumber embolization often needs second interventions and close surveillances. In addition, intervention to treat endoleaks also has some risks of complications. In this point, there is a question if these methods are ...

Transcaval approach for embolization of type II Endoleak following endovascular aortic aneurysm repair

“…Currently there is no consensus as to the optimal treatment strategy for T2E. The indication for treatment typically includes persistent endoleak (> 6 months) and continued sac expansion (> 0.5 cm) (Yamada et al, 2015; Ozdemir et al, 2013). Frequently used strategies include: 1) transarterial embolization of the feeding vessel accessed from the superior mesenteric or internal iliac artery collaterals; and 2) embolization via direct sac puncture from a translumbar (Ozdemir et al, 2013) or transabdominal (Zener et al, 2018) approach.…”

Intraoperative Findings of an Atypical Type II Endoleak from an Artery within the Aneurysmal Wall after Endovascular Aneurysm Repair

“…For typical type II endoleaks such as those of the lumbar artery and IMA, surgical ligation of the causative blood vessel and sacotomy have been highly successful. 7) If the culprit blood vessel in the present case was an anatomical variation, this approach should be effective. Conversely, if the vessel was part of the vasa vasorum, whether this treatment would be the optimal management is unclear.…”

Type II Endoleaks After EVAR: A Literature Review of Current Concepts

“…50 This technique is free from incompletely treated endoleak, and this means that patients will not need subsequent interventions and periodical hospital attendings. 42 Maitrias et al 51 reported a series of 21 patients with TIIEL, with a 100% success rate treated by an open approach with stent-graft preservation. Moulakakis et al 52 also reported a 100% success rate on 22 patients treated by OSR with sacotomy and suturing of feeding vessels, with a complication rate of 13.6%.…”

“…Besides, using CT guidance and fluoroscopy causes high radiation exposure to the patients. 42 Complications of these techniques include atrial fibrillation, myocardial infarction, pseudoaneurysm, multiple organ failure, bowel ischemia, renal artery perforation, pneumonia, sepsis, or retroperitoneal bleeding. 43 Infection of the endograft after treatment for TIIEL has also been reported.…”

“…50 This technique is free from incompletely treated endoleak, and this means that patients will not need subsequent interventions and periodical hospital attendings. 42 Maitrias et al 51 Stent graft preservation, aortic clamp avoidance, and careful operative planning seem to improve results in these difficult cases. 53 Laparoscopic surgery (LS) with clipping/ligation at the origin of the IMA has been reported more rarely with very few cases.…”