Outcome of endoleak following endoluminal abdominal aortic aneurysm repair

BACKGROUND: The most important complication of endoluminal abdominal aortic aneurysm repair is endoleak, in which there is persistent blood flow outside the graft but within the aneurysm sac. Depending on endoleak type, there is an ongoing potential for aneurysm expansion or rupture. Conversely, some endoleaks may resolve spontaneously. Absolute indications for interventional management of endoleaks remain elusive due to the heterogeneous nature of leaks and uncertainty in predicting their outcome. METHODS: A retrospective review was conducted on all endoluminal graft recipients with endoleaks at Repatriation General Hospital over a 3-year period. Data were collected via a database maintained by the Department of Vascular Surgery, and hospital casenotes. RESULTS: Sixty-six patients underwent endoluminal graft insertion in the study period. Fourteen endoleaks were observed in 11 patients, representing an endoleak rate of 21.2%. There were three type I leaks and 11 type II leaks. One type I leak resolved spontaneously, one resolved immediately following interventional management, and one resolved 6 months after interventional management. Interventional treatment was undertaken in seven cases of type II leak due to increase in aneurysm diameter by 5 mm. Two type II endoleaks resolved spontaneously. Aneurysm diameter increased in two patients following radiographic resolution of their endoleaks. There were no cases of aneurysm rupture. CONCLUSIONS: Initial observation is a reasonable management option in most cases of type II endoleak, because some will spontaneously resolve during follow up. Those associated with increase in aneurysm size should undergo interventional treatment. Conservative management of type I endoleaks may be undertaken in extreme isolated cases.     

A complication of open abdominal aortic aneurysm repair closely resembling a type II endoleak

Endoleak is a well-recognized complication of endovascular treatment of abdominal aortic aneurysms. Despite over 40 years of open transabdominal aortic aneurysm surgery, only in the last decade has endoleak as a complication of open surgery been described. Endoleak after conventional open surgery was first described by Chan et al in 2000 and remains a rare complication. We describe the first reported case of type II endoleak (back-bleeding inferior mesenteric artery) after open repair of abdominal aortic aneurysm, and its successful management by endovascular coil embolization.     

Endovascular repair of late abdominal aortic aneurysm rupture owing to mixed-type endoleak following endovascular abdominal aortic aneurysm repair

We report the successful endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 8 months after endovascular abdominal aortic aneurysm repair (EVAR). A 74-year-old man with a history of EVAR 8 months earlier presented with hypotension, severe back pain, and tenderness on abdominal palpation. A contrast-enhanced computed tomographic scan showed a large retroperitoneal hematoma and confirmed the diagnosis of secondary abdominal aortic rupture. Because the patient had severe comorbidities, the endovascular method was chosen for further management. Two stent grafts were placed appropriately to eliminate a type 1a and a type 3 endoleak owing to modular separation of the left iliac graft limb from the main body stent graft. An additional self-expanding stent was deployed in the solitary right renal artery to open its origin, which was partially overlapped by the proximal cuff. The patient was discharged on the tenth postoperative day and is alive and well 1 year postoperatively. This case indicates that endovascular repair is feasible not only in cases of primarily ruptured AAAs but also in secondarily ruptured AAAs after failure of EVAR.     

Acute symptomatic abdominal aortic aneurysm secondary to endovascular stent graft associated type II endoleak

Endovascular abdominal aneurysm repair (EVAR) is popular because of its low invasiveness and feasibility for high-risk patients. Endoleak is common after EVAR and is characterized by blood flow within the aneurysm sac but outside the stent graft. Type II or collateral endoleak commonly results from retrograde filling of the aneurysm from collateral visceral vessels, lumbar, inferior mesenteric, accessory renal or sacral arteries. Collateral leaks are generally thought to be benign and over half of the early leaks will seal spontaneously. Sporadically, collateral endoleak could lead to aneurysm sac pressurization and place the patient at ongoing risk of rupture. Herein, we report an uncommon case of early post-stent graft placement symptomatic abdominal aortic aneurysm associated with type II endoleak.     

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.     

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.     

腹主动脉瘤腔内治疗并发症内漏的诊治

目的 探讨血管内技术治疗腹主动脉瘤时特有并发症内漏的诊断与处理方法。方法 对已施行腔内治疗37例腹主动脉瘤患者进行回顾性分析,讨论部分患者并发内漏的原因、诊断、处理、结果及预后。结果 37例支架型血管放置完成后,13例发现存在不同程度的内漏,其中I型6例,Ⅱ型3例,Ⅲ型2例,Ⅳ型1例,不明原因1例,1期经相关技术处理后I型、Ⅲ型内漏完全消失。手术结束时原发性内漏发生率13．5％（5／37）。随诊发现原发性内漏3例自愈,2例转化为持续性内漏;另发现2例继发性内漏发生率13．5％（5／37）。随诊发现原发性内漏3例自愈,2例转化为持续性内漏;另发现2例继发发现人漏。本组患者晚期内漏发生率10．8％（4／37）。结论 引起漏血的原因可能与瘤颈形态、长度、成角、钙化、移植物选择、分支血管血液倒流等因素有关。强调术中发现并一期处理,术后应密切随访。增强CT、血管超声和MRA检查是术检后检测内漏的主要手段。对漏血量及瘤体有增大趋势的内漏应积极处理。     

超声诊断腹主动脉瘤腔内隔绝术后内漏

目前主要采用腹主动脉瘤腔内隔绝术（EVAR）治疗腹主动脉瘤,术后内漏发生率较高;监测EVAR术后有无内漏发生是随访的主要目的。超声检查具有操作方便、价格低廉、无电离辐射等优点,检出内漏的敏感度和特异度均较高。本文围绕超声诊断EVAR术后内漏进展进行综述。     

腹主动脉瘤腔内修复术后内漏的临床诊治

腹主动脉瘤腔内修复术(endovascular aneurysmrepair,EVAR)具有明显的减少术中出血,缩短手术及住院时间,减少手术并发症,促进术后恢复等优势,尤其使有心、脑、肺严重合并症而不能耐受腹主动脉瘤切除术的高危病人获得救治机会。随着该项技术的日益成熟和血管支架的不断完善,腔内     

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。     

Late lumbar hemorrhage after open repair of abdominal aortic aneurysm: computed tomographic appearance resembling type II endoleak

Development of endoleak after conventional open repair of abdominal aortic aneurysm is less well documented compared with endovascular stenting. We present a case report of a 65-year-old man who had sudden onset of back pain with central abdominal tenderness 34 days after successful open repair of an abdominal aortic aneurysm. Urgent laparotomy revealed the presence of a noninfective intrasac hemorrhage, due to recanalization of the lumbar arteries. These were successfully suture ligated. Delayed lumbar hemorrhage should be an important differential diagnosis by frontline medical personnel in patients with recent open aneurysm repair. The recent literature on other causes and management strategies is also reviewed.     

A meta-analysis of translumbar embolization versus transarterial embolization for type II endoleak after endovascular repair of abdominal aortic aneurysm

ObjectiveThis systematic review and meta-analysis aimed to compare the clinical outcomes between transarterial and translumbar (direct aneurysm sac puncture) approaches for persistent type II endoleak after endovascular repair of abdominal aortic aneurysm.MethodsWe searched multiple electronic databases (up to October 31, 2018) for eligible trials in patients with type II endoleaks after endovascular abdominal aortic aneurysm repairs that evaluated the outcomes of translumbar embolization vs transarterial embolization. The primary outcome was clinical success (absence of the endoleak on the last examination); the secondary outcomes were technical success and complication rate. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated.ResultsAmong the 904 studies screened, 9 studies with 354 participants were included in this review. None of the studies reported rupture or mortality. The translumbar group had a relatively higher clinical success rate than the transarterial group, but this difference was not statistically significant (OR, 2.29; 95% CI, 1.00-5.25; P = .05; I² = 52%). The technical success rate was significantly higher in the translumbar group than in the transarterial group (OR, 13.32; 95% CI, 3.41-52.07; P = .0002; I² = 0%). No significant difference was found in the complication rate of the two groups (OR, 1.15; 95% CI, 0.26-4.96; P = .85; I² = 0%). We also included five studies that reported the clinical outcomes of open repair. All patients were technically treated by open repair, and 58 of 60 patients owned clinical success during the follow-up period.ConclusionsThe translumbar route was more successful in obliterating the endoleak on follow-up imaging. When repeated endovascular embolizations fail, a laparotomy should follow.     

兔腹主动脉瘤模型的建立

目的：探讨一种简便、成功率高的兔腹主动脉瘤（AAA）模型建立的方法。
方法:健康雄性新西兰大白兔20只,随机分为实验组和对照组（各10只）,实验组应用CaCl2浸润法建模,对照组应用生理盐水浸润法。6周后观察两组动物腹主动脉扩张率、大体形态学及显微病理改变。
结果:实验组兔腹主动脉直径扩张至（124.12±8.11）%,与对照组相比差异有统计学意义（P＜0.01）。实验组腹主动脉的病理改变为中膜弹性纤维组织严重破坏,平滑肌细胞减少。
结论:CaCl2溶液浸润法制作兔AAA模型简单可行,为AAA的实验性治疗研究提供一种合适的造模方法。

     

Successful glue embolization of a late type 1A endoleak causing abdominal aortic aneurysm rupture

We describe the successful treatment with n-butyl cyanoacrylate embolization of a ruptured infrarenal abdominal aortic aneurysm caused by a late type-1A endoleak 10 years after endovascular aneurysm repair (EVAR).