腹主动脉瘤腔内修复术后各型内漏相关性分析（附272例报告）

目的: 探讨腹主动脉瘤（abdominal aortic aneurysm, AAA）腔内修复术后发生内漏的危险因素。方法: 回顾性分析2014年1月至2015年10月272例AAA病人行腔内修复术的临床资料和术后3、6、12、24、36个月随访结果。分析腔内修复术后各型内漏发生率及其与临床特征、支架类型、动脉瘤颈结构的关系。结果: 272例病人腔内修复术后内漏总发生率为15.8%(43/272),其中Ⅰ、Ⅱ、Ⅲ或Ⅳ型以及张力性内漏（Ⅴ型）的发生率分别为7.4%(20/272)、6.3%(17/272)、1.5%(4/272)和0.7%(2/272)。Ⅰ型内漏多在随访3个月时发现,而其他类型内漏在随访12个月或更晚发现。动脉瘤近端瘤颈短（<1.5 cm）、重度扭曲（>45°）、形状不规则或钙化程度高（>25%）与Ⅰa型内漏发生显著相关（P<0.05）。持续通畅的肠系膜下动脉以及存在≥2根罪犯血管是Ⅱ型内漏发生的危险因素（P<0.05）。年龄、美国麻醉医师协会（American Society of Anesthesiologists, ASA）病情分级、吸烟以及合并高血压、糖尿病、冠心病、肺部疾病等对内漏发生率无影响。不同类型的人工血管支架对内漏发生有显著影响（P=0.047）。与其他类型支架相比,Endurant支架的内漏发生率最低（10.7%）。结论: 制定腔内修复手术方案时,应充分评估AAA的特征和内漏风险,以期达到较好的疗效。     

EVAR reintervention management strategies in contemporary practice

It is known that following an endovascular aneurysm repair (EVAR) procedure, patients may experience endoleaks, device migration, stent fractures, graft deterioration, or aneurysm growth that might require a reintervention. In this review management strategies of reinterventions after EVAR in contemporary practice will be discussed. The current endovascular treatment options of Type I endoleak involve securing of the attachment site with percutaneous transluminal balloon angioplasty, stent-graft extension, or placement of a stent at the proximal attachment site. Moreover, the use of endostaples to secure the position of the proximal cuff to the primary endograft have been developed. Type II endoleaks can be managed conservatively if the aneurysm is shrinking or remains stable. Otherwise, reinterventions include transarterial embolization, translumbar embolization, transcaval embolization, direct thrombin injection, and endoscopic or open ligation of the lumbar and mesenteric arteries. There is little debate regarding the treatment of type III endoleaks, including deployement of additional stent graft components to bridge the defect. Endovascular treatment of endotension includes endovascular conversion stent or relining of the stent graft. Alternative options are puncture of the aneurysm sac and removal of the aneurysm sac content. In case of migration large balloon-expandable stents can be used to improve the seal between the components, or devices that deploy staples to secure endovascular grafts to the aortic wall to secure endovascular components together. In conclusion, the first treatment options for reinterventions after EVAR are catheter based nowadays.     

Successful treatment of endotension and aneurysm sac enlargement with endovascular stent graft reinforcement

Abdominal aortic aneurysm (AAA) enlarges after successful endovascular repair because of endoleak, which is persistent blood flow within the aneurysm sac. In the absence of detectable endoleak, AAA may still expand, in part because of endotension, which is persistent pressurization within the excluded aneurysm. We report three patients who underwent successful endovascular AAA repair using the Excluder device (W. L. Gore & Associates, Flagstaff, Ariz). Although their postoperative surveillance showed an initial aneurysm regression, delayed aneurysm enlargement developed in all three, apparently due to endotension. Endovascular treatment was performed in which endograft reinforcement with a combination of aortic cuff and iliac endograft extenders were inserted in the previously implanted stent grafts. The endograft reinforcement procedure successfully resulted in aneurysm sac regression in all three patients. Our study underscores the significance of increased graft permeability as a mechanism of endotension and delayed aneurysm enlargement after successful endovascular AAA repair. In addition, our cases illustrate the feasibility and efficacy of an endovascular treatment strategy when endotension and aneurysm sac enlargement develops after endovascular AAA repair.     

Nonoperative approach to endotension

OBJECTIVE: The necessity of operative treatment of endotension after endovascular grafting of abdominal aortic aneurysms (endovascular aneurysm repair; EVAR) is under debate. The proposed causes of endotension and related treatment protocols are controversial. We report the outcome of a nonoperative approach to five patients with endotension after EVAR. METHODS: From February 1997 to August 2004, 160 patients who underwent EVAR of an infrarenal abdominal aortic aneurysm were evaluated for the incidence of endotension. According to the endovascular protocol, plain radiographs, spiral computed tomography, and angiography were performed before and after surgery for follow-up. To detect endotension, spiral computed tomography was performed by using a delayed imaging technique after the infusion of contrast medium. Endotension was defined as an aneurysm sac enlargement after EVAR without evidence of endoleak. Aneurysm sac rupture was defined as discontinuity of the calcific rim of the aneurysmal sac and the presence of intra-aneurysmal fluid outside the sac. RESULTS: We found five (3.1%) patients with endotension. Three of these experienced aneurysmal sac rupture. Only one of the three was underwent operation on experiencing sudden intestinal occlusion due to intra-abdominal adhesions. This patient had no intra-abdominal or retroperitoneal bleeding or hematoma but died after intensive care as a result of non-aneurysm-related problems. Four patients with endotension are still being closely followed up according to our surveillance protocol, and they are doing clinically well. After rupture, clear shrinking of the aneurysm sac was seen in two patients. CONCLUSIONS: Endotension after EVAR may cause subsequent aneurysm rupture. Endotension is evidently not associated with endoleak I to III provided that the endovascular graft is maintained in appropriate position and that free endovascular flow is observed. We propose to consider a nonoperative approach in the clinically asymptomatic patient with aneurysm enlargement after EVAR if endoleak is excluded by well-performed imaging techniques.     

Management of a large intraoperative type IIIb endoleak in a bifurcated endograft-a case report

The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.     

Midterm outcomes of AFX2 endografts used in combination with aortic cuffs

ObjectiveType III endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Endologix unibody endograft remain a major concern, despite fabric, system, and instructional updates. The purpose of this study was to examine real-world outcomes of repairing AAAs using the current version of the AFX2 main body in combination with an aortic cuff, specifically focusing on type III endoleaks and morphological changes of the endograft.MethodsWe recruited facilities in Japan that used AFX2 combined with an aortic cuff for at least five cases between April 2017 and March 2018. A total of 175 cases in 24 facilities were analyzed. Patients’ background information, including anatomic factors, operative findings, device component variations, and midterm outcomes at 3 years after the EVAR were collected. The data on computed tomography scans from cases registered as types I and III endoleaks and migration from each institute were sent to our department for verification.ResultsThe mean patient age was 74.6 ± 8.1 years, and 48 cases (27%) were saccular aneurysms. The mean fusiform and saccular AAA diameters were 50.5 ± 5.8 mm and 43.5 ± 8.9 mm, respectively. No in-hospital deaths occurred. Data at 3 years, including computed tomography images, of 128 cases were analyzed. Overall survival, freedom from aneurysm-related mortality, and freedom from reintervention rates at 3 years were 85.8%, 99.3%, and 87.3%, respectively. There were three, one, and three cases of types I, IIIa, and IIIb endoleaks without sac dilatations, respectively. Among five migration cases, one case of aortic cuff migration presented as a type Ia endoleak, and four cases demonstrated sideways displacement, one of which presented as a type IIIa endoleak. The sac regression and enlargement rates at 3 years were 41.4% and 20.5% in the fusiform group and 44.2% and 16.7% in the saccular group, respectively. The proximal neck diameter slightly increased from 20.8 ± 2.7 mm before the EVAR to 22.2 ± 4.6 mm after the repair.ConclusionsMidterm outcomes of the AFX2 used in combination with an aortic cuff were acceptable, considering the rates of types I and III endoleaks. However, there were cases of sideways displacement that could cause future type IIIa endoleaks. When the AFX2 is used in combination with an aortic cuff, close surveillance for endograft deformations and subsequent adverse events, including type III endoleaks, is needed.     

What is the significance of endoleaks and endotension

Endovascular repair has been used over a decade as a treatment of abdominal aortic aneurysm, and has become a widely accepted treatment method with a low rate of perioperative complications. Endoleak, perigraft blood flow outside endograft but within aneurysmsac, has been intensively studied during the last 10 years of endovascular aneurysm repair (EVR). The natural history of aneurysms with endoleak and the true clinical significance of various types of endoleaks remains unclear. Type I/III endoleak has been found to be associated with aneurysm rupture, while the risk of rupture of aneurysms with type II endoleak and endotension appears very small. In endotension, the aneurysm sac remains pressurized, even if there is no evidence of an endoleak. Currently,it is accepted that type I/III endoleaks should be corrected, preferably by endovascular means, due to the risk of rupture. If endovascular repair is not possible, then open conversion should be considered. The risk of conversion should be weighed against the risk of aneurysm rupture. Treatment of type II endoleaks and endotension is more controversial. In those with aneurysm enlargement,secondary interventions are often performed.     

腹主动脉瘤腔内修复术后Ⅱ型内漏发生的危险因素分析及其处理

目的 探讨腹主动脉瘤（AAA）腔内修复（EVAR）术后Ⅱ型内漏发生的影响因素。方法 回顾性分析2006年1月至2011年3月期间四川大学华西医院血管外科行EVAR术的197例AAA患者的临床资料,并探讨Ⅱ型内漏发生的影响因素。结果 197例患者行EVAR后发生Ⅱ型内漏18例。logistic回归分析结果显示,腰动脉数量每增加１根,发生Ⅱ型内漏的风险增加了0.822倍（OR=1.822,P=0.010）;最大腰动脉直径每增加1 mm,发生Ⅱ型内漏的风险增加了0.256倍（OR=1.256,P=0.040）。197例患者获访1～36个月,中位数为16.8个月。随访期间,1例瘤体直径于术后6个月时增长大于5 mm,给予经股动脉以弹簧圈栓塞肠系膜下动脉分支处理,术后内漏消失;余17患者的内漏自行封闭或瘤体直径无明显变化。结论 腰动脉数量和最大腰动脉直径均可影响Ⅱ型内漏的发生。如果持续性Ⅱ型内漏的瘤体直径无明显变化,可暂不处理,但应密切随访。     

Using bilateral iliac branch devices for endovascular iliac aneurysm repair

Introduction: The endovascular repair of bilateral iliac aneurysms using bilateral Iliac Branch Devices (IBDs) has been infrequently performed and reported. We aim to describe this technique and report on the results of our case series. Methods: Three different device designs are available. The procedural options include a totally transfemoral approach, or a combined transfemoral and brachial approach. Clinical records for patients who have had this procedure were reviewed. Results: The indications for the technique include bilateral common iliac artery aneurysm repair, with or without concomitant abdominal aortic aneurysm repair. Considerations include the timing of main body endovascular aortic aneurysm repair (EVAR) device introduction, the use of a proximal access site and the type of IIA stent‐graft that is used. Between 2007 and 2010, six patients had bilateral IBD implantation. All patients required an EVAR main body device in addition to bilateral IBDs. Eighty‐three per cent were males, mean age was 73 years. Mean follow up was 15 months. Technical success was obtained in 100% of cases. There was one branch occlusion (8.3%). There were no type I endoleaks. One patient had a type II endoleak. Conclusions: Bilateral IBDs can be used safely and with excellent rates of technical success and branch patency in appropriately selected patients.     

Ischemic Colitis following Translumbar Thrombin Injection for Treatment of Endoleak

Endoleaks remain a significant challenge after endovascular abdominal aortic aneurysm repair (EVAR). Translumbar thrombin injection of the aneurysm sac has been used to treat endoleaks, with low reported morbidity. We present an unusual case of ischemic colitis following translumbar thrombin injection of an endoleak. A 67-year-old male with a 5.8-cm abdominal aortic aneurysm (AAA) was evaluated for endograft repair. The patient underwent preoperative embolization of the right hypogastric artery. The AAA was repaired using a unibody bifurcated graft (Ancure). Completion aortogram revealed no endoleak and a widely patent left hypogastric artery. Computed tomography (CT) at 2 months showed an endoleak appearing to originate from a lumbar artery near the proximal attachment site with outflow via the inferior mesenteric artery (IMA). The endoleak was successfully treated with CT-guided translumbar injection of 8000 units of thrombin into the aneurysm sac. The patient subsequently developed chronic abdominal pain, diarrhea, and a weight loss of 20 lbs. Colonoscopy revealed ischemic colitis of the rectosigmoid colon. Duplex evaluation indicated a patent superior mesenteric artery and IMA distal to its origin. Medical treatment failed and the patient underwent a low anterior resection 2 months later (4 months post-EVAR). Subsequently, the aneurysm has decreased to 5.4 cm, with no evidence of endoleak at 1 year. We conclude that ischemic colitis may occur following translumbar thrombin injection. Thrombin embolization into the rectosigmoid arcade via the IMA was most likely the cause in this case. This problem can potentially be avoided by treating the IMA endoleak outflow prior to translumbar thrombin injection of the aneurysm sac. Thorough arteriographic evaluation of endoleaks should be performed prior to any interventions. Presented at the Annual Meeting of the Southern California Vascular Surgical Society, Carlsbad, CA, April 11-13, 2003.     

Sac enlargement without endoleak: when and how to convert and technical considerations

The primary goal of endovascular treatment of abdominal aortic aneurysms (AAA) is prevention of death from rupture. Even in the absence of an endoleak, the AAA may continue to enlarge. The pathogenesis of this phenomenon remains unclear. Therefore, surveillance after endovascular AAA treatment must include regular evaluation of aneurysm size, or even better, aneurysm volume. Aneurysm sac enlargement without an endoleak is not a benign condition. Recurrent or persistent pressurization of the AAA sac will eventually result in rupture. Besides that, continued expansion of the AAA sac can result in dilatation of the infrarenal neck and/or iliac arteries, which may threaten the integrity of proximal and distal anastomotic seals. Many centers will take a pragmatic approach in case of endotension and a growing AAA, and convert to open surgery with removal of the endograft and placement of a regular vascular graft. Direct puncture and pharmacological intervention in the cause of sac enlargement by local instillation seems logical, but has failed so far. The third option for aneurysm sac enlargement without an endoleak is laparoscopic or open fenestration of the aneurysm. Until permanent solutions for endotension and endoleaks are found, endovascular aneurysm repair will remain an imperfect long-term treatment and continued follow-up will be mandatory.     

Increasing use of open conversion for late complications after endovascular aortic aneurysm repair

ObjectiveOpen procedures are often required for late complications after endovascular aneurysm repair (EVAR). Our aim was to describe the indications for open interventions and their postoperative outcomes and to specifically examine our experience with limited conversions in which problem endoleaks are targeted without endograft explantation.MethodsWe reviewed patients from 2002 to 2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, preoperative imaging, procedural details, and postoperative outcomes were reviewed. The primary end point was 30-day mortality.ResultsThere were 102 patients who underwent open conversion 3.8 ± 3.1 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016; 48.5% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 85 patients and infection in 15. One patient had a limb occlusion and another a proximal aneurysm. The 30-day mortality was 6.2% in 65 patients treated electively for endoleak but higher in 20 ruptures (40.0%) and 15 infections (40.0%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (odds ratio [OR], 6.70; 95% confidence interval [CI], 1.75-25.60; P = .005), endograft infection (OR, 8.48; 95% CI, 1.99-36.20; P = .004), and use of a supraceliac clamp (OR, 4.80; 95% CI, 1.47-15.66; P = .009). Transient acute kidney injury (12.8%) and prolonged intubation (11.8%) were the most common postoperative complications. In 65 patients treated for endoleak without rupture, 37 underwent endograft explantation, whereas 28 had a graft-preserving intervention (branch vessel ligation for type II endoleak in 26, external banding of the aneurysm neck for type IA endoleak in 8). Mortality was 8.1% when the endograft was explanted and 3.6% when it was not (P = .63). During 3.0 ± 3.5 years of follow-up, there was one reintervention after endograft explantation (for rupture secondary to type IB endoleak) and two reinterventions after graft preservation (for a new type IA endoleak and a new type II endoleak). Survival was 87.4% at 1 year and 70.9% at 5 years.ConclusionsOpen conversion is playing an increasing role in the management of late EVAR complications. Endoleaks treated electively by open conversion are reasonably safe and show good midterm durability, even with graft-preserving interventions that avoid endograft explantation.     

Endovascular conversion with femorofemoral bypass as a treatment of endotension and aneurysm sac enlargement

We report a case of a patient treated with a Gore Excluder endograft for AAA in November 2003 with subsequent aneurysm sac enlargement in the absence of an identified endoleak. The patient had a Type I endoleak treated with a Palmaz stent at the neck and later developed a Type II endoleak treated with translumbar coil embolization. This was successful with absence of pressure in the sac after the procedure and stable aneurysm size over the next nine months. Surveillance of the patient with both CT and ultrasound then revealed an increase in the aortic sac diameter in the absence of endoleak. A Cook Zenith converter was used to reline this PTFE endograft. Subsequently, imaging showed aneurysm sac shrinkage. This is a report of endotension with aneurysm expansion following Gore Excluder placement which was treated successfully with a dacron endograft.     

Freedom from endoleak after endovascular aneurysm repair does not equal treatment success.

OBJECTIVE: To determine whether freedom from endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) is a reliable guide to freedom from persistent or recurrent pressurisation of the aneurysm sac (endotension) and therefore freedom from risk of rupture. PATIENTS AND METHODS: The records of 55 patients followed for more than 3 months after EVAR were reviewed to correlate the presence or absence of endoleak on contrast-enhanced CT and/or angiography with changes in maximum aneurysm diameter (DMAX). RESULTS: in 22 (40%) patients there was no significant change in DMAX during follow-up. In 21 of these no endoleak was observed on CT or angiography. One patient developed a secondary side-branch endoleak which remains under observation. In 18 (33%) patients, DMAX decreased during follow-up. Thirteen of these remained free of endoleak. Four patients developed secondary endoleaks which were treated by secondary intervention. One patient with persistent primary endoleak suffered fatal aneurysm rupture three days before planned intervention. DMAX increased in 15 (27%) patients. In only five of these could an endoleak be identified on CT and/or angiography. One primary side-branch endoleak persists following failed embolisation. Four secondary endoleaks have been corrected by secondary intervention. Four of the remaining 10 patients died suddenly from unknown cause. All had DMAX greater than 65 mm at last follow-up. One patient underwent late conversion, which suggested continued pressurisation through thrombus at the site of a "sealed" primary proximal endoleak. Two patients are scheduled to undergo embolisation of patent side-branches revealed only by Levovist enhanced Duplex scanning and three patients remain under observation. CONCLUSION: Freedom from endoleak on conventional imaging incorrectly suggested freedom from endotension in 10 (18%) of our patients. Follow-up after endovascular repair must include regular measurement of DMAX and/or aneurysm sac volume to identify those patients who remain at risk of rupture.     

合并双髂总动脉瘤的腹主动脉瘤的腔内治疗

目的总结腹主动脉瘤合并双髂总动脉瘤的腔内治疗经验。方法2009年1月～2012年3月,126例腹主动脉瘤接受腔内修复术（endovascularaneurysmrepair,EVAR）,其中33例合并双髂总动脉瘤（直径〉18mm）。27例双侧髂总动脉直径〉18-〈25mm,选择合适口径的髂腿移植物完成传统EVAR;6例因-侧髂总动脉直径≥25mm,选择该侧髂外动脉作为锚定区完成EVAR,并行髂内动脉栓塞术。结果所有腔内技术均获得成功,手术时间（115±36）min,出血量（173±65）m1。术中发现即刻内漏7例（21．2％）：I型内漏3例（近端1例,远端2例,均经球囊扩张后内漏消失）;11I型内漏1例,经扩张后内漏消失;II型内漏2例,Ⅳ型内漏1例,经随访瘤体直径未增大,未予处理。33例术后随访6～39个月,平均15．3月,无动脉瘤破裂,无远端迟发型I型内漏发生,髂动脉直径无明显扩张。结论对于部分合并双髂动脉瘤的腹主动脉瘤患者,根据髂总动脉直径选择合适的腔内治疗方法可以达到理想的治疗效果,近期效果满意。     

Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference

OBJECTIVE: Endoleaks and endotension are critically important complications of some endovascular aortic aneurysm repairs (EVARs). For the resolution of controversial issues and the determination of areas of uncertainty relating to these complications, a conference of 27 interested leaders was held on November 20, 2000. METHODS: These 27 participants (21 vascular surgeons, five interventional radiologists, one cardiologist) had previously answered 40 key questions on endoleaks and endotension. At the conference, these 40 questions and participant answers were discussed and in some cases modified to determine points of agreement (consensus), near consensus (prevailing opinion), or disagreement. RESULTS: Conference discussion added two modified questions for a total of 42 key questions for the participants. Interestingly, consensus was reached on the answers to 24 of 42 or 57% of the questions, and near consensus was reached on 14 of 42 or 33% of the questions. Only with the answers to four of 42 or 10% of the questions was there persistent controversy or disagreement. CONCLUSION: The current endoleak classification system with some important modifications is adequate. Types I and II endoleak occur after 0 to 10% and 10% to 25% of EVARs, respectively. Many (30% to 100%) type II endoleaks will seal and have no detrimental effect, which never or rarely occurs with type I endoleaks. Not all endoleaks can be visualized with any technique, and increased pressure (endotension) can be transmitted through clot. Aneurysm pulsatility after EVAR correlates poorly with endoleaks and endotension. An enlarging aneurysm after EVAR mandates surgical or interventional treatment. These and other conclusions will help to resolve controversy and aid in the management of these vexing complications and should also point the way to future research in this field.     

Treatment of an early type II endoleak causing hemorrhage after endovascular aneurysm repair for ruptured abdominal aortic aneurysm

We report a case of ruptured abdominal aortic aneurysm emergently treated by endovascular aneurysm repair (EVAR) that developed a primary type II endoleak leading to persistent blood loss and retroperitoneal hematoma increase. Coil embolization resolved this. Although to our knowledge there are no recommendations regarding this, our report suggests that early type II endoleaks occurring after emergency EVAR for ruptured AAA should be treated when it is associated with blood extravasation outside the aneurysm sac.     

Conformational changes associated with proximal seal zone failure in abdominal aortic endografts

OBJECTIVE: Endovascular aneurysm repair (EVAR) has become a popular treatment for abdominal aortic aneurysm (AAA). This study examines conformational changes in the infrarenal aortas of patients in whom proximal seal zone failures (PSF) developed after EVAR. METHODS: All 189 patients with aortic endograft underwent routine post-EVAR computed tomographic scan surveillance. Patients identified with proximal type I endoleaks, type III endoleaks, or proximal component separation without demonstrable endoleak underwent three-dimensional reconstruction of the computed tomographic scans from which measurements of the migration, length, volume, and angulation of the infrarenal aorta were made. RESULTS: Five patients (3%) had PSF develop, four of whom had aortic extender cuffs. Although changes in the AAA volume and aortic neck angle were slight or variable, the mean AAA length increased 34 mm and the mean aortic body angulation increased 17 degrees (P =.03 and.01, respectively). Lengthening and migration caused proximal component separation in four patients, with concomitant migration in two patients. Two patients underwent endovascular repair, two patients needed explantation of the endograft, and one patient awaits endovascular repair. Proximal component separation and type III endoleak recurred in one patient and were repaired with a custom-fitted graft. CONCLUSION: PSF of aortic endografts is associated with proximal angulation and lengthening of the infrarenal aorta. These findings reinforce the importance of proper initial deployment to minimize the need for aortic extender cuffs, which pose a risk of late endoleak development.     

Treatment of a primary type IA endoleak with a liquid embolic system under conditions of aortic occlusion

We present the case of a primary type IA endoleak after deployment of a bifurcated Ancure endograft (Guidant Endovascular Solutions, Menlo Park, Calif) to treat a 9-cm abdominal aortic aneurysm with a short angulated neck. The endoleak was treated unsuccessfully with repeat balloon angioplasty, placement of a Palmaz aortic stent (Cordis Endovascular, Miami, Fla), and deployment of an AneuRx aortic extender cuff (Medtronic AneuRx, Santa Rosa, Calif). The endoleak then was sealed with injection of n-butyl cyanoacrylate into the aneurysm sac at the site of the leak with occlusion of aortic flow. We suggest the use of this liquid embolic agent be considered as an adjunct to control primary type IA endoleaks when other forms of therapy have failed.     

Clinical Significance of Type II Endoleak after Endovascular Repair of Abdominal Aortic Aneurysm

Type II endoleaks after endovascular repair of abdominal aortic aneurysm (EVAR) are a result of retrograde flow from arterial branches (e.g., lumbar and inferior mesenteric) refilling the aneurysm sac, which has been excluded by the stent graft. Controversy continues with regard to the clinical significance and treatment of type II endoleaks. To develop recommendations for management, we analyzed outcome data from 10 EVAR trials completed over the last 5 years involving a total of 2,617 cases. The incidence of type II endoleak at discharge or 30 days was 6-17%, at 6 months 4.5-8%, and at 1 year 1-5%. Successful resolution of endoleak following secondary interventions was observed in 11-100% of cases. There were 10 conversions to open repair and no ruptures related to type II endoleak. In patients observed for 12 months with computed tomography and/or ultrasound, approximately one-half of type II endoleaks disappeared spontaneously. In the absence of a type I endoleak, our analysis of the current literature suggests that intervention for type II endoleak should be undertaken for abdominal aortic aneurysm sac enlargement occurring after 6 months, persistence for >12 months without abdominal aortic aneurysm sac enlargement, or an aneurysm sac pressure >20% of systolic blood pressure; translumbar aneurysm sac thrombosis and intra-arterial feeding vessel occlusion appear to be prudent management options. Presented at the Twenty-second Annual Meeting of the Southern California Vascular Surgery Society, San Diego, CA, May 1, 2004.