Laparoscopic transperitoneal clipping of the inferior mesenteric artery for the management of type II endoleak after endovascular repair of an aneurysm

We report the case of a high risk patient with an abdominal infrarenal aortic aneurysm (AAA) who was treated by endovascular technique and the subsequent management of a type II endoleak by the laparoscopic approach. In this case, a 74-year-old woman with a 6-cm infrarenal AAA underwent endovascular repair using a bifurcated stent-graft device. Surveillance CT scan showed a persistent type II endoleak at 1 week and 3 months after the operation. Angiography confirmed retrograde flow from the inferior mesenteric artery (IMA). Attempted transarterial embolization of the IMA via the superior mesenteric artery was not successful. Laparoscopic transperitoneal IMA clipping was performed. Subsequent aortic duplex scan and CT scan confirmed complete elimination of the type II endoleak. We conclude that a combination of endovascular and laparoscopic procedures can be used to manage AAA successfully.     

腹主动脉腔内修复术后II型内漏的栓塞治疗：附3例报告

目的:探讨腹主动脉腔内修复术(EVAR)后Ⅱ型内漏的治疗方法。方法:回顾性分析2011—2016年中南大学湘雅医院血管外科治疗的3例EVAR术后比较严重的Ⅱ型内漏患者的临床资料,1例胸腹主动脉瘤行杂交手术(开放手术重建内脏血管+EVAR)后瘤体继续增大,检查发现为腹腔干动脉反流性内漏;另外2例均为腹主动脉瘤行EVAR术后肠系膜下动脉反流性内漏。结果:腹腔干动脉反流性内漏患者用Interlock可解脱弹簧圈系统栓塞,另外2例采用普通弹簧圈栓塞。3例栓塞均获得成功,内漏消失。结论:EVAR术后Ⅱ型内漏采用不同的入路栓塞是行之有效的方法。     

Preoperative hepatic insufficiency and type III endoleak: a confirmed potential fatal association following endovascular treatment

Consumptive coagulopathy is known to occur in patients with aneurysm, especially in the thoracic localization. Compared to open chest surgery, the endovascular treatment leaves in place a large thrombosed aneurysmal sac, which might induce and/or exacerbate the coagulopathy. Although exceptional, some recent reports have raised the potential disastrous issue related to this complication. We report the case of a 74-year-old patient treated for an asymptomatic thoracic aorta aneurysm by endoprosthesis who developed a fatal disseminated intravascular coagulopathy. This complication has been related to a type III endoleak associated with a preoperative hepatic insufficiency.     

Novel technique for treatment of a renal artery occlusion in a child with neurofibromatosis: a combined endovascular and laparoscopic approach

Neurofibromatosis is associated with mid-aortic dysplasia, renal artery aneurysms and renal artery ostial stenosis, or occlusions in about 1% of cases. We describe a novel approach to recanalize an occluded renal artery in a 10-year-old girl with neurofibromatosis and difficulty in pharmacologically controlling her hypertension. Normally, when reconstruction is required, an open operative technique is used. We report on the combined use of laparoscopic exposure and percutaneous retrograde puncture of the occluded renal artery, which could be recanalized and stented. The pros and cons of this new approach are discussed.     

Transcaval embolization of a type I gutter endoleak after three-vessel chimney endovascular aneurysm repair

Chimney endovascular aneurysm repair provides an endovascular treatment for complex aortic aneurysms. However, type I gutter endoleaks can complicate this approach and prevent full aneurysm exclusion. Treatment of these leaks can be challenging. We report successful embolization of a type I gutter endoleak after (chimney endovascular aneurysm repair) via a transcaval approach.     

Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach.

We report an unusual case of type IV Thoracoabdominal Aneurysm (TAA) with Superior Mesenteric Artery (SMA), celiac artery, and bilateral renal artery aneurysms in a patient who underwent an earlier repair of two infrarenal Abdominal Aortic Aneurysm (AAA) ruptures. Because of the presence of the visceral artery aneurysms and the earlier operation through the retroperitoneum, standard surgical treatment via a retroperitoneal approach with an inclusion grafting technique was considered difficult. A combined surgical approach achieving retrograde perfusion of all four visceral vessels and endovascular grafting allowing exclusion of the TAA was accomplished. Complete exclusion of the aneurysm and normal perfusion of the patient's viscera was documented by means of follow-up examinations at 3 and 6 months. The repair of a type IV TAA with a Combined Endovascular and Surgical Approach (CESA) allowed us to manage both the aortic and visceral aneurysms without thoracotomy or re-do retroperitoneal exposure and minimized visceral ischemia time. If the durability of this approach is confirmed, it may represent an attractive alternative in patients with aneurysmal involvement of the visceral segment of the aorta.     

Complex thoracic aortic aneurysm: a combined open and endovascular approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

Primary aortoenteric fistula following endovascular aortic repair due to type II endoleak

An 84-year-old female was lost to follow-up after endovascular aneurysm repair at another hospital with known type II endoleak. She later presented with presyncope and hematemesis. A referral center esophagogastroduodenoscopy showed possible duodenal diverticulum. She had recurrent symptoms and repeat computed tomography scan showed air within the aortic sac. At our center, she underwent stent graft explantation and axillofemoral reconstruction for a primary aortoenteric fistula. She was discharged and is doing well 5 months postoperatively. A high degree of suspicion for aortoenteric fistula is imperative in any patient with upper gastrointestinal hemorrhage after open or endovascular abdominal aortic aneurysm repair.     

Double-chimney technology for treating secondary type I endoleak after endovascular repair for complicated thoracic aortic dissection

Endovascular repair continues to pose a formidable technical challenge in the cases of aneurysm, dissection, and proximal type I endoleak involving the aortic arch. During the process of covering the aortic arch by stent graft to achieve better sealing, maintaining blood flow to the vital supra-aortic branches is difficult. We present a case of successful endovascular treatment of secondary type I endoleak by a double-chimney technique in a 36-year-old woman who had previously undergone a complicated descending aortic dissection repair. This endovascular technology might offer a new option to simultaneously preserve the innominate artery and the left carotid artery for total reconstruction of the aortic arch.     

Total robotic ligation of inferior mesenteric artery for type II endoleak after endovascular aneurysm repair

We present a case of totally robotic ligation of the inferior mesenteric artery (IMA) for treatment of a persistent endoleak from the IMA into the aneurysm sac after endovascular aneurysm repair (EVAR). An 84-year-old male underwent EVAR with a Gore Excluder stent graft for an asymptomatic infrarenal abdominal aortic aneurysm. Follow-up computed tomographic (CT) scan showed persistent type II endoleak from the IMA, with progressive enlargement of the aneurysm sac from 5 to 6.1 cm over an 18-month period. In this case, the patient underwent ligation of the IMA using the da Vinci Surgical System for the treatment of retrograde flow into the aneurysm sac. The total operating time was 249 min; of this, the robotic assistance time was approximately 180 min. No intraoperative complications occurred. The estimated blood loss was 50 mL and the urine output 650 mL. The patient was extubated immediately after the procedure and tolerated a regular diet the following day. He was discharged home with a urinary catheter on postoperative day 2. CT scan postoperatively and at 3-month follow-up demonstrated an occluded IMA and stabilization of the aneurysm sac size.     

Endoscopic type 2 endoleak repair following endovascular aortic aneurysm repair: acute results and follow-up experience

The purpose of this study was to evaluate immediate and long-term results of endoscopic type 2 endoleak repair (EER) following endovascular abdominal aortic aneurysm repair. The basic methods include a retrospective review of electronic and paper medical records of patients admitted or referred to our institution for EER. Between July 1999 and October 2007, eight consecutive patients underwent EER. Mean operative time was 190 (104-355) min. One patient died preoperatively, due to profuse venous bleeding . One procedure was redone due to a missed pair of lumbar arteries. Mean hospital stay was five days (2-10). During mean follow-up, 50 months (29-91), one patient required additional coil embolization for a persistent type 2 endoleak. Four patients were diagnosed with a type 1 and one with a type 3 endoleak; three of these patients required an additional procedure. In conclusion, in this small series EER proved not to be beneficial.     

Type II endoleak after endovascular abdominal aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective

OBJECTIVES: The conservative versus therapeutic approach to type II endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) has been controversial. The purpose of this study was to evaluate the safety and cost-effectiveness of the conservative approach of embolizing type II endoleak only when persistent for more than 6 months and associated with aneurysm sac growth of 5 mm or more. METHODS: Data for 486 consecutive patients who underwent EVAR were analyzed for incidence and outcome of type II endoleaks. Spiral computed tomography (CT) scans were reviewed, and patient outcome was evaluated at either office visit or telephone contact. Patients with new or late-appearing type II endoleak were evaluated with spiral CT at 6-month intervals to evaluate both persistence of the endoleak and size of the aneurysm sac. Persistent (>or=6 months) type II endoleak and aneurysm sac growth of 5 mm or greater were treated with either translumbar glue or coil embolization of the lumbar source, or transarterial coil embolization of the inferior mesenteric artery. RESULTS: Type II endoleaks were detected in 90 (18.5%) patients. With a mean follow-up of 21.7 +/- 16 months, only 35 (7.2%) patients had type II endoleak that persisted for 6 months or longer. Aneurysm sac enlargement was noted in 5 patients, representing 1% of the total series. All 5 patients underwent successful translumbar sac embolization (n = 4) or transarterial inferior mesenteric artery embolization (n = 4) at a mean follow-up of 18.2 +/- 8.0 months, with no recurrence or aneurysm sac growth. No patient with treated or untreated type II endoleak has had rupture of the aneurysm. The mean global cost for treatment of persistent type II endoleak associated with aneurysm sac growth was US dollars 6695.50 (hospital cost plus physician reimbursement). Treatment in the 30 patients with persistent type II endoleak but no aneurysm sac growth would have represented an additional cost of US dollars 200000 or more. The presence or absence of a type II endoleak did not affect survival (78% vs 73%) at 48 months. CONCLUSIONS: Selective intervention to treat type II endoleak that persists for 6 months and is associated with aneurysm enlargement seems to be both safe and cost-effective. Longer follow-up will determine whether this conservative approach to management of type II endoleak is the standard of care.     

腹主动脉瘤腔内隔绝术后内漏的研究

目的　探讨腹主动脉瘤腔内隔绝术后内漏的处理方法。方法　建立犬腹主动脉瘤模型 ,植入自制的腔内移植物建立内漏模型 ,采用瘤腔内注射纤维蛋白胶的方法消除内漏 ,测定瘤腔内压力变化。结果　对照组在腔内隔绝术前瘤腔内平均动脉压和脉压差分别为 (16.89± 0 .2 4)、(4 .45± 1.3 0 )kPa ,术后分别为 (5 .5 5± 0 .13 )、(0 .0 7± 0 .0 1)kPa ,均明显下降 (P <0 .0 1) ;而实验组瘤腔内术前平均动脉压和脉压差分别为 (17.11± 0 .2 6)、(4 .65± 1.5 7)kPa ,在内漏状态下分别为 (18.0 9± 0 .3 4)、(4 .12± 0 .3 7)kPa ,无明显变化 (P >0 .0 5 ) ;瘤腔内注射纤维蛋白胶后血管造影示内漏消失 ,此时瘤腔内平均动脉压和脉压差分别为 (2 0 .2 2± 0 .3 2 )、(1.19± 0 .13 )kPa ,即压力不会立即下降 ,但脉压差会显著下降 (P <0 .0 1) ,且压力曲线基本接近一条直线。结论　瘤腔内压力可以作为判定腔内隔绝术成功与否的标准之一 ,也可以作为术中判断内漏存在的指标之一。采用经动脉插管到瘤腔内或者瘤壁直接穿刺注射促凝血药物治疗术中内漏可行。