Abstract
IntroductionType 2 endoleaks (T2Es) after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) can lead to sac expansion or failure of sac regression, and often present as a management dilemma. The intraluminal thrombus (ILT) may influence the likelihood of endoleaks after EVAR and can be characterized using routine preoperative imaging. We examined the relationship between preoperative spatial morphology of ILT and the incidence of postoperative T2E.MethodsAll patients who underwent EVAR at the John Radcliffe Hospital (Oxford, UK) were prospectively entered in a clinical database. Computed tomography angiograms (CTAs) were performed as part of routine clinical care. The ILT morphology of each patient was determined using the preoperative CTA. Arterial phase cross-sectional images of the AAA were analyzed according to the presence and morphology of the thrombus in each quadrant. The overall ILT morphology was defined by measurements obtained over a 4-cm segment of the AAA. The diagnosis of T2Es during EVAR surveillance was confirmed by CTAs. The relation between the ILT morphology and T2E was assessed using logistic regression.ResultsBetween September 2009 and July 2016, 271 patients underwent EVAR for infrarenal AAAs (male: 241, age = 79 ± 7). The ILT was present in 265 (98%) of AAAs. Mean follow-up was 1.9 ± 1.6 years. The T2E was observed in 77 cases. Sixty-one percent of T2Es were observed within the first week after surgery. The T2E was observed in 50% (3/6) of cases without the ILT (no-ILT). Compared with no-ILT, the presence of circumferential or posterolateral ILTs was protective from T2Es (odds ratio = 0.33 and 0.37; P = 0.002 and P = 0.047, respectively).ConclusionsThe spatial ILT morphology on routine preoperative CTA imaging can be a biomarker for post-EVAR T2Es. ILTs that cover the posterolateral aspects of the lumen, or circumferential ILTs, are protective of T2Es. This information can be useful in the preoperative planning of EVARs.
Highlights
Type 2 endoleaks (T2Es) after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) can lead to sac expansion or failure of sac regression, and often present as a management dilemma
This study had 63 participants with various sizes of AAAs, using either US or CT (42 US, 21 CT) as the diagnostic tool. This literature predated the evidence-based guidelines on size threshold for intervention in AAA, yet it still underpins the common clinical understanding regarding the prevalence of intraluminal thrombus (ILT) in AAAs
Each of the patients had a high-resolution CT scan performed for preoperative planning, which allows for objective assessments for the prevalence of ILT within the AAA sac
Summary
Type 2 endoleaks (T2Es) after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) can lead to sac expansion or failure of sac regression, and often present as a management dilemma. The intraluminal thrombus (ILT) within AAAs has previously been held as a bystander to the disease.[11] emerging evidence indicates ILT to be biologically active and contains inflammatory cells within a network of canaliculi.12e14 It is possible that native ILTs within the AAA sac are directly involved in the post-EVAR aneurysm sac remodeling process This is supported by a magnetic resonance imaging study of patients with nonsac shrinkage after EVAR demonstrated significantly more nonorganized thrombus in patients with an endoleak.[15] There are prior observations of lower endoleak and sac enlargement rates with more sac surface area coverage by ILT,16e18 but there is little literature regarding the link between the spatial locations of ILT preoperatively, and the occurrence of endoleaks after EVAR
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