Direct Sac Research Articles

Understanding Type II Endoleak: A Harmless Imaging Finding or a Silent Threat?

Type II endoleak (T2EL) represents a challenging clinical entity following endovascular abdominal aortic aneurysm repair (EVAR). Although several studies have suggested that T2ELs are related to an increased risk of aneurysm sac growth and subsequent rupture, the exact role that T2ELs play in long-term outcomes remains debatable. Understanding the pathophysiology, diagnostic modalities, and management options of T2ELs is important for patients' safety and proper resource utilization. While conservative management may be suitable for asymptomatic patients with a stable aneurysm size, interventional approaches, including transarterial embolization, direct sac puncture embolization and open conversion have been described for patients with persistent T2EL associated with sac expansion. However, more research is needed to better determine the clinical benefit of such interventions. A thorough evaluation of all endoleak types before T2EL treatment would be reasonable for patients with T2ELs associated with sac expansion. Further studies are needed to refine treatment strategies aimed at minimizing T2EL-related complications. Collaborative efforts among vascular specialists, radiologists, and researchers are of paramount importance to address this ongoing clinical challenge.

Mortality and risk factors for ruptured abdominal aortic aneurysm after repair endovascular (rARE).

The aim of this study was to characterize risk factors for infrarenal abdominal aortic aneurysm rupture after endovascular repair (rARE) and evaluate 30-day mortality in comparison to primary ruptured abdominal aortic aneurysm (rAAA). A retrospective review of all adult patients with rAAA at a single tertiary university care center between February 11, 2006, and December 31, 2018, was performed. A total of 267 patients with rAAA were identified, 11 of whom had rARE. Descriptive statistics were applied due to the small sample size. Overall 30-day mortality was similar between primary rAAA and rARE (31.5% vs 27.3%); however, patients with rARE were more likely to receive palliative care (3.9% vs 18.2%). Mortality of patients who underwent operative intervention was 11.1% for rARE and 28.7% for primary rAAA at 30days. All patients had an endoleak at the time of rupture. Type 1 and type 3 endoleaks resulting in direct aortic sac pressurization were the primary cause of rARE (9 of 11 patients); however, rupture occurred in two patients with only a type 2 endoleak. There was no sac expansion at the time of rupture in four of 11 patients with rARE. Four of 11 patients were lost to follow-up prior to rARE. rARE is an uncommon complication following EVAR and contributes to late aneurysm-related mortality following endovascular repair. Although the 30-day mortality rate was similar for rARE and primary rAAA, larger series are required to determine which patients with rARE will benefit from intervention. The presence of endoleak and sac expansion may alert surgeons to increased risk of rARE; however, a subset of patients with rARE did not have sac expansion or surveillance imaging on follow-up. Loss to lifelong imaging surveillance remains a risk factor for rARE.

Abstract No. 34 Comparison of Type II Endoleak Treatment: Direct Sac Puncture versus Transarterial Embolization: A Retrospective Cohort Analysis

Type II endoleak remains one of the most common complications after endovascular aneurysm repair. The current study compares outcomes of type II endoleak embolization using direct sac puncture approach versus transarterial embolization in patients treated with endovascular repair of aortic aneurysms in a single-center retrospective cohort. This a retrospective observational cohort of patients who underwent percutaneous treatment of type II endoleak from 2008 to 2017. Patients were divided into 2 groups: embolization of endoleak via transarterial approach (group A) and embolization of endoleak via direct puncture of the sac (group B). Outcomes were compared between groups by the Pearson χ2 tests. A total of 87 consecutive patients (mean age, 77.4 y; range, 61–93 y) were included in the study, 85% were men and 15% were women. Mean interval from endovascular aneurysm repair to embolization was 20.7 months ± 15.8 with a median of 17 months (range, 0–79 months). Median follow up was 47 months (range, 2–105 months). There was a significant difference between clinical success, determined by sac decrease/stabilization on follow-up CT, of direct sac puncture vs. transarterial embolization (77% vs 46%; P = .011). There was significantly higher clinical success with embolization of type II endoleak via a direct sac puncture compared with transarterial embolization in our retrospective cohort on first attempt intervention.

Direct sac puncture versus transarterial embolization of type II endoleaks after endovascular abdominal aortic aneurysm repair: Comparison of outcomes.

Type 2 endoleak (T2EL) is the most common type of endoleak after endovascular abdominal aortic aneurysm repair (EVAR), and increases the risk of aneurysm sac rupture if it persists beyond 6 months. The purpose of this study is to compare the efficacy and safety of direct sac puncture versus transarterial embolization of T2ELs. Retrospective review of 42 consecutive T2EL embolization procedures, 19 by DSP and 23 by transarterial technique, between January 2015 and December 2020. Primary outcome was aneurysm sac stability and resolution of endoleak at follow-up imaging. Adverse events (AE) were classified based on the Society of Interventional Radiology (SIR) practice guidelines. Technical success was 94.7% (18/19) in the DSP group and 86.9% (20/23) in the transarterial group (p = 0.32 (-0.77-0.25)). Treatment efficacy was evaluated in 16 patients in the DSP group and 18 patients in the transarterial group who had follow-up imaging ≥6months after embolization. Mean imaging follow-up was 17.1 ± 11.2 (range, 6-41) months in the DSP group and 26.5 ± 15.4 (range, 6-48) months in the transarterial group (p = 0.06, -19.24-0.37). Treatment efficacy was 75% (12/16) in the DSP group and 33.3% (6/18) in the transarterial group (p = 0.02, 95% CI, 0.09-0.97). There was no procedure-related mortality. Moderate-severe AE occurred in 15.7% (3/19) in the DSP group and 8.7% (2/23) in the transarterial group (p = 0.44, -0.12-0.26). In this study, DSP embolization of T2EL was equally safe and more effective than transarterial embolization in achieving aneurysm sac stability and resolution of endoleak.

Incarcerated left-sided Amyand’s hernia and synchronous ipsilateral femoral hernia: first case report

BackgroundThe finding of a vermiform appendix within the peritoneal sac of an inguinal hernia is called Amyand’s hernia. The reported incidence of Amyand’s hernia and femoral hernia is 1% and 3.8%, respectively. To our knowledge, no cases have been reported in the literature that associate these two entities. We present the first case of incarcerated left-sided Amyand’s hernia and synchronous ipsilateral femoral hernia found during emergency surgery.Case presentationA 72-year-old woman was admitted to the Emergency Department for a complicated left inguinal hernia. An inguinotomy was performed that detected a large direct hernial sac and a synchronous femoral hernia. The opening of the inguinal hernia showed the presence of the cecum and the appendix, both without signs of inflammation. The femoral space was evaluated transinguinally, identifying the larger omentum that had slipped into the femoral canal. The primary closure of the posterior wall defect was performed with the McVay technique due to its large size, and then the hernioplasty was completed with a polypropylene mesh. No postoperative complications were reported.ConclusionsIn the context of an incarcerated Amyand’s hernia, the decision to perform an appendectomy in addition to hernia repair with or without mesh will depend on intraoperative findings.

Evaluation of the Effectiveness of Endovascular Treatment of Type 2 Endoleaks

Endovascular abdominal aortic aneurysm repair (EVAR) is a safe and minimally invasive alternative to open surgical repair for infra renal aortic aneuvrysm. EVAR requires lifelong post-procedural surveillance. Endoleaks represent the main complication. Type II endoleaks (EL2) are the most frequent and tend to be indolent. Most practitioners do not treat in EL2 as long as they are associated with stable aneurysm diameter. European guidelines recommend treatment in case of aneurysm growth. Several techniques can be offered, such as transarterial embolization and translumbar embolization. This study reports the experience and results of a single center for EL2 endovascular treatment. The aim of this study was to determine more precisely the efficacity of embolization for type 2 endoleaks treatment. A single center cohort of patients treated for EL2 with endovascular technique between 1998 and 2018 was formed to perform a descriptive analysis. Preoperative sizing, risk factors of endoleaks and intraoperative data were collected. Computed topography (CT) scans were regularly performed after EVAR to detect endoleak recurrence. Clinical recurrence was defined as the persistence of aneurysm sac growth and radiological recurrence was defined as the occurrence of EL2 on a post-embolization CT scan. Data related to reintervention, overall mortality and aneurysm related mortality were also collected. Kaplan-Meier survival analyses were used to determine the rates of reoperation-free survival and recurrence-free survival. Six hundred seven patients underwent an endovascular treatment for abdominal aorta aneurysm between 1998 and 2018. One hundred forty-five type 2 endoleaks occurred during this period. Nineteen patients (median age 76years), underwent endovascular treatment for EL2, with immediate success on 15 patients (8 transarterial embolization, 8 direct sac puncture and 3 combined procedures). During follow-up, 5 patients required a new translumbar embolization and 6 required an open surgery for recurrence of the EL2. Six patients died, 2 of them of causes related to the aneurysm. At 59,6months median follow-up, 53% of the patients presented a radiologic recurrence, with a sac growth of more than 5mm since last procedure in 4 patients (24%). Long term clinical recurrence of type 2 endoleaks treated by endovascular procedures appear to be frequent in our experience, leading to several deaths and requiring open surgical treatment.

Abstract No. 73 Direct sac puncture versus transarterial embolization of type II endoleaks after endovascular abdominal aortic aneurysm repair: comparison of outcomes

Abstract No. 73 Direct sac puncture versus transarterial embolization of type II endoleaks after endovascular abdominal aortic aneurysm repair: comparison of outcomes

Direct Aneurysm Sac Guided Aspiration: a “MAGIC” Bullet for Diagnosing Aortic (Endo)graft Infections?

Vascular graft and endografts infections (VGEIs) have high mortality rates. As emphasised by the European Society for Vascular Surgery (ESVS) guidelines, “when a vascular graft/endograft infection is suspected, it is recommended that every effort is made to obtain microbiological proof of infection”.1 However, the performance of pre-operative samples is inadequately understood, and current recommendations are partly based on the experience of bone and joint infections (BJI).1

Guided Aspiration for Determining the Microbiological Aetiology of Aortic Vascular Graft and Endograft Infections

Open and endovascular aortic repair may be complicated by aortic vascular graft or endograft infection (VGEI). Confirming the microbiological aetiology is a key element in providing the best available treatment to patients with a VGEI. The primary aim of this study was to describe the technique of direct aneurysm sac guided aspiration (DASGA) in determining the microbiological aetiology in a cohort of patients with VGEIs, and to report its diagnostic value. This was a retrospective observational single centre study performed between the years 2011 to 2020 in Malmö, Sweden. Patients with a suspected aortic VGEI, where a DASGA was performed at the Vascular Centre, were included in the study. In total, 31 guided aspirations were performed in 27 patients (25 male [93%]; median age 77 years [range 57 - 82 years]). The combination of culture and 16S rRNA/18S rRNA gave a microbial aetiology in 25/31 (81%) DASGAs. Importantly, excluding three cases where infection was ruled out, this rate increases up to 89%. A polymicrobial aetiology was found in six (24 %) cases. The most common bacteria found were Cutibacterium spp. (n= 8) and Listeria monocytogenes (n= 4). In total, the dominant aetiology could be further characterised into normal gut flora (n= 12; 48%) or skin commensals (n= 8; 32%). No patients had persistent morbidity related to the DASGA. DASGA can be used successfully to determine the microbiological aetiology of open and endovascular graft infections. This method appears to be safe, with a high success rate for confirming the microbiological aetiology of VGEIs, particularly if standard culturing methods are combined with 16S rRNA/18S rRNA. Finding the causative microbial aetiology is crucial, and in the vast majority of cases translumbar puncture can be used without serious complications.

Ultrasound-Guided Transgraft and Transcaval Embolization of Type II Endoleak

Type II endoleak is a common and often unavoidable complication following endovascular aortic aneurysm repair. Most endoleaks are transient and will either resolve spontaneously or remain benign. However, persistent type II endoleaks can be associated with aneurysmal sac expansion and, even, rupture. The optimal treatment strategy for these endoleaks depends on the source, location, and collateral network of the feeding vessels. The most frequent strategies for embolization include transarterial access of the feeding vessel and translumbar embolization via direct sac puncture.

An Unusual Finding of Ipsilateral Pantaloon Hernia with Contralateral Direct inguinal Hernia in a Male Cadaver

The presence of unilateral Pantaloon's hernia with contralateral direct hernia coexisting together is a rare occurrence. We noticed such a case, where in one male cadaver aged 78 years on routine cadaveric dissection. A case of unilateral Pantaloon hernia was observed where both direct and indirect hernial sac were observed in the inguinal region on the right side while on the left side a huge direct inguinal hernial sac was present with coils of sigmoid colon as its content. Here, we have discussed this rare occurrence of composite hernias with their contents in a single body in detail with the associated morphological distortions and possible complications.

Complicated embolisation of late endoleak via direct sac puncture: not all endoleaks are a type II endoleak

BackgroundEndoleaks after endovascular aortic aneurysm repair (EVAR) occur frequently with type 2 being the most common. Treatment of type 2 endoleaks is indicated if the aneurysmal sac increases in size.Case reportIn this case report, we will discuss a patient who presented with aneurysmal sac size increase 11 years after undergoing EVAR for an asymptomatic abdominal aortic aneurysm which extended into the iliac arteries. Multi-phase CT demonstrated an endoleak with features commonly seen in type 2 endoleaks; pooling of contrast near a lumbar artery orifice on the angiographic phase which increases during the delayed phase. Both internal iliac arteries were sacrificed during the initial EVAR. Percutaneous direct sac puncture was therefor performed and angiogram during the procedure revealed no feeding or draining lumbar arteries. During attempts to embolize the perfused part of the aneurysmal sac non-target embolization into the main body of the graft occurred and the presence of type 3b endoleak was confirmed. The non-target embolization did not result in permanent sequelae.ConclusionsType 3b endoleaks are rare and can mimic type 2 endoleaks, which can cause serious complications if not identified properly. Rapid increase in aneurysmal sac size is uncommonly seen in type 2 endoleaks and if present needs to trigger further diagnostic investigations.

Pantaloon Hernia in a Female: A Rare Finding

The incidence of inguinal hernia in females is less compared to the males. Pantaloon hernia in females is even rarer and may be first diagnosed during surgery. We report a rare case of pantaloon hernia in a 60 year old female patient. She presented with reducible left groin swelling of 3 years duration and a clinical diagnosis of an indirect inguinal hernia made. A direct sac and an indirect sac were discovered at operation on both sides of the inferior epigastric artery. The posterior wall was repaired by Lichtenstein method. Patient made an uneventful recovery and there was no recurrence after 12 months of follow up. Though pantaloon hernia is rare in females, proper dissection, and identification of structure in the inguinal canal is necessary to make the correct diagnosis and to offer the appropriate treatment.

Type 2 Endoleak Management.

Type 2 endoleaks are the most common endoleak type following endovascular aneurysm repair. The natural history of these endoleaks can vary, with some demonstrating a self-limited or indolent course, while others can contribute to aneurysm sac enlargement and rupture. A variety of embolization techniques, including transarterial catheterization and direct sac puncture techniques, have been developed for the treatment of type 2 endoleaks. In this article, the authors review the indications, techniques, and outcomes of current treatment strategies for type 2 endoleaks.

Direct percutaneous embolization of aneurysm sac: a safe and effective procedure to treat post-EVAR type II endoleaks

To report safety and effectiveness of type II endoleak embolization, with percutaneous direct aneurysm sac puncture. Fifty patients, 31 male (mean age 55 ± 5), with post-EVAR type-II endoleak underwent direct percutaneous sac puncture for embolization. Procedures were performed, under local anesthesia. Sac puncture was done using a 20G needle under rotational angiography guidance. A coaxial system (4Fr catheter + 2.7 microcatheter) was used to navigate the sac. During the follow-up period, all patients underwent contrast-enhanced ultrasound (CEUS) at 6 and 12months. Technical success, with complete exclusion of the aneurysm sac, was achieved in all cases. Time of procedure varied between 36 and 68min (mean 51.36min). Mean fluoroscopy time was 16.7min. A posterior left access was used in 41 cases, posterior right access in 6 cases, and an anterior approach in 3. In 19 cases (38%), one or more feeding vessels were visualized and embolized. Sac embolization was done using Onyx plus micro-coils in 31 cases (62%) and Onyx alone in 19 cases (38%). Mean amount of Onyx was 6ml. No complications, correlated with the direct percutaneous sac puncture, or to Onyx injection occurred. After 1-year follow-up, sac shrinkage occurred in 34 cases (68%), while in 16 patients (32%) sac size remained stable without evidence of sac perfusion. Percutaneous direct sac embolization using Onyx in combination or not with microcoils represents a safe and valid technique to solve post-EVAR type II endoleaks.

Immediate and 1-year success rate of type 2 endoleak treatment using three-dimensional image fusion guidance

PurposeTo retrospectively assess immediate and 1-year success rate of type 2 endoleak (T2E) treatment with ethylene-vinyl-alcohol-polymer using three-dimensional (3D) image fusion guidance with cone beam computed tomography via trans-arterial embolization (TAE) or direct percutaneous sac injection (DPSI). Materials and methodsA total of 37 patients with T2E who were treated either using TAE (34/37; 92%) or DPSI (9/37; 8%) were included. There were 34 men and 3 women with a mean age of 86±9 (SD) years (range: 67–104years). Mean aneurysm diameter was 67±14 (SD) mm (range: 42–101mm) at pre-procedure evaluation. Immediate success was complete embolization of the sac and feeding artery. 1-year success was reduction or stability of the aneurysmal sac diameter based on pre-procedure and 12-month follow-up examinations. Safety (treatment-related complications), patient demographics, duration of procedure and contrast volume were reported. ResultsImmediate and 1-year successful outcomes were reported in 94% (n=32) and 88% (n=28) of patients after TAE and 100% (n=9) and 89% (n=8) after DPSI. T2E treatments were immediately successful for 95% of the procedures (41/43) and for 88% (36/41) at 1year. Overall, T2E treatment was effective in 33 patients (89%). No major complications occurred. Mean procedure time and contrast volume were significantly different between the 2 techniques with respectively 87±16 (SD) min (range: 65–120min) and 75±26 (SD) mL (range: 40–130mL) for TAE and 32±10 (SD) min (range: 20–50min) (P<0.01) and 6±6 (SD) mL (range: 2–22mL) (P<0.01) for DPSI. Mean aneurysm diameter at 1-year was 68±17 (SD) mm (range: 43–101mm). No significant differences in the pre-procedure sac diameter were found at long-term follow-up between patients without T2E and those with persistent T2E (P=0.1) in the successful embolization group (n=33). ConclusionTAE or DPSI treatments of T2E with ethylene-vinyl-alcohol-polymer using 3D-image fusion guidance were immediately successful for 95% of the procedures and remained effective for 88%. Longer follow-up is necessary to assess sac stability in the case of persistent endoleak.

3:09 PM Abstract No. 183 Let’s get straight to the point: direct sac puncture for type II endoleak embolization is technically superior to endovascular management

3:09 PM Abstract No. 183 Let’s get straight to the point: direct sac puncture for type II endoleak embolization is technically superior to endovascular management

Comparison of Experimental Infection of Normal and Immunosuppressed Chickens with Mycoplasma gallisepticum

Four different models of infection of chickens with Mycoplasma gallisepticum (MG) were evaluated. Normal or immunosuppressed chicks (10 days old) were infected with the MG Rlow strain via eye and nasal drops or by direct air sac injection. Bacterial load in the lungs was quantified and air sac and tracheal lesion scores, tracheal mucosal thickness and humoral immune responses were assessed. Serum antibody responses were assessed by use of a serum plate agglutination test. Three days post infection (dpi), all immunosuppressed chicks had developed significant respiratory signs. Chicks infected via air sac injection had significant differences in serum antibody and gross lesion scores at 5 dpi. All chicks had developed pathological changes by 7 dpi. Air sac inoculation of immunosuppressed chicks produced more significant (P≤0.05) lesions, and these birds had the highest bacterial load in the lungs compared with other groups.

Pantaloon hernia with two sliding components

An inguinal hernia is quite frequent in surgical praxis. One of the rare entities sliding type of inguinal hernia with an incidence of 2%–5%, which is difficult to diagnose preoperatively, most of the time, its diagnosis is made on the operational table. We report a rare case of pantaloon-type hernia with sliding components in either side of the hernia: the appendix, ascending colon onto the lateral, indirect hernia sac, and the urinary bladder onto the medial, direct sac, respectively. The two hernia sacs were saddled on either side of the inferior epigastric vessels. A 77-year-old presented with a right inguinoscrotal swelling for 5 years and increased frequency of micturition for 8 months. The indirect sac was opened very cautiously and was found to contain an appendix, the part of urinary bladder medially and ascending colon laterally forming the sliding component, small bowel, omentum are the contents of sliding hernia. The contents were attenuated and the sac was sealed cautiously. The posterior wall of the right inguinal canal was opened in total, contents were reduced, and neo posterior wall is formed by strengthening, and reinforcement did with prolene mesh. This entity is a diagnostic dispute due to its rarity and defined clinical presentation. Pantaloons hernia with two sliding components is uncommon. The hernia consisted of two parts: a laterally-located indirect sac containing the appendix and sliding ascending colon, and a medially-located direct hernia of sliding urinary bladder. A hernia of long duration in old patients should raise a suspicion of a pantaloon-type hernia. One should be very careful to identify the contents of the hernia to avoid inadvertent injury to the structures.

03:27 PM Abstract No. 26 Embolization of type II endoleaks via a percutaneous trans-abdominal direct sac puncture approach: a comparison of outcomes of embolizing the aneurysm sac only versus the aneurysm sac and branch vessels

To compare outcomes of type II endoleak embolization involving embolization of the aneurysm sac alone versus the aneurysm sac and branch vessels via a percutaneous trans-abdominal direct sac puncture approach. This retrospective review comprised of 37 consecutive patients (28 men, 9 women; mean age = 78.3 years) who underwent 46 percutaneous trans-abdominal direct sac puncture embolization procedures for type II endoleaks after EVAR from 2011 to 2018. Patients were divided into 2 groups; embolization of the aneurysm sac alone (Group A) and embolization of the aneurysm sac and branch vessels (Group B). Outcomes between the groups were compared by Mann-Whitney U and Pearson χ2 test. The primary outcome was freedom of aneurysm growth, which was defined as <5% aneurysm sac volume change on follow-up computed tomography (CT) imaging or < 5 mm aneurysm sac diameter on ultrasound with no evidence of endoflow within the sac. Technical success was achieved in 97% (36/37). Mean follow-up time were 17.1 months ± 12.6 in group A and 31.1 months ± 19.1 in group B. Embolization agents included cyanoacrylate glue only (61%), glue and coils (30%), and Onyx with or without coils (9%). Types of grafts deployed included infra-renal bifurcated grafts (78%), fenestrated grafts (13%), aorto uni-iliac grafts (7%), and thoracic graft (2%). There was no statistical difference in the freedom of aneurysm growth (54% vs 65%, Group A vs B, p = 0.44) or residual type II endoleak (46% vs 45%, Group A vs B, p = 0.94) between the two groups. No major procedural-related complications encountered. There is no significant difference in the freedom of aneurysm growth when embolizing the aneurysm sac alone versus embolizing the aneurysm sac and branch vessels for type II endoleaks via a percutaneous trans-abdominal direct sac puncture approach.