Type II Endoleak Research Articles

Impact of Type-II Endoleak on Aneurysm Sac Growth and Preoperative Predictors of Type-II Endoleak

Purpose Type-II endoleak (T-II-EL) after endovascular abdominal aneurysm repair (EVAR) is an unresolved problem. Our purpose was to investigate the impact of T-II-EL on aneurysm sac growth and to identify potential preoperative T-II-EL predictors. Material and Methods We enrolled 162 consecutive patients (Zenith: 61, EXCLUDER: 57, ENDURANT: 44) who underwent successful EVAR without Type-I or Type-III endoleak and had at least 1-year follow-up. Computed tomography (CT) before and after EVAR (1 week, 6 month, and 1 year) were reviewed to estimate T-II-EL and measure sac diameter. Three-dimensional volume analyses were performed during CT for measuring sac volume. Vessel number and diameter of the patent lumbar artery (LA) and inferior mesenteric artery (IMA) were determined. Various anatomical parameters and patient characteristics were investigated as possible T-II-EL predictors. Results T-II-EL was 35.8%, 15.4%, and 12.3% at 1 week, 6 months, and 1 year after EVAR, respectively. The mean preoperative maximum sac diameter and volume were 50.1 ± 8.2 mm and 153.8 ± 75.5 mL, respectively, without differences between T-II-EL cases (T-II-group) and absence of T-II-EL cases (non-T-II-groups). Significant differences in the reduction of sac diameter (T-II-group: -0.11 ± 3.4 mm vs. non-T-II-group: -7.3 ± 6.0 mm; p Conclusions Persistent T-II-EL after EVAR was observed in 12% of patients in the current stent graft system. DAPT and EXCLUDER use were independent predictors of persistent T-II-EL. Sac growth was observed in half of the patients with persistent T-II-EL. Because T-II-EL with patent IMA was significantly associated with sac growth, careful observation and additional intervention may be considered.

Tratamiento endovascular del aneurisma de aorta: endoleaks tipo ii, cuándo y cómo tratarlos

IntroductionThe treatment of type ii endoleaks remains controversial. Their long-term natural history and impact on changes in aneurysm morphology are still under review. ObjectiveThe objective of this study is to present a safe and effective approach to treat type ii endoleaks associated to aneurysm sac enlargement. Material and methodOut of a total of 214 patients, 32 presented with a type II endoleak in the first post-surgical review. Fifteen of these developed a persistent endoleak, but only 11 of them were associated with growth of the aneurysm sac. The treatment consisted of coil embolisation of the lumbar arteries (8 cases), lumbar puncture (one case), embolisation of the inferior mesenteric artery (IMA) (one case), and laparoscopic IMA ligation (one case). The data were analysed using the Medcalc v. 11 statistics package. ResultsBy transarterial or laparoscopic techniques effective treatment was obtained of endoleak, evidenced by its stabilization thrombosis and aneurysm sac in successive tomographic controls. No mortality or reoperation related rupture occurred. ConclusionOnly those patients with persistent typeII endoleak associated with sac enlargement should be treated. Effective techniques were described.

Treatment of type II endoleak after abdominal aortic aneurysm endovascular repair

To explore the treatment of type II endoleak (TEE) after the endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). From January 2009 to July 2011, 10 patients with type II endoleak after AAA EVAR were recruited. Different treatment methods were employed for the criminal arteries, including transcatheter embolization with coils, percutaneous sac puncture, intrasac injection of fibrin glue and outcome follow-up. Among them, 9 patients underwent treatment and 8 received a mean follow-up of (2.4 ± 1.6) months. The mean secondary time was (62 ± 39) months. The criminal arteries were inferior mesenteric artery (n = 3), internal iliac artery (IA) (n = 1), IA with lumbar artery (n = 3) and lumbar artery (n = 3). Two patients died from cardiovascular and cerebrovascular events during the follow-up. The primary technical success was 44%, retreat rate 33% and clinical success rate 89%. Type II endoleak has a relatively benign course. In the absence of sac expansion, it can be followed for a long period of time without the needs for intervention. Treatment is necessary when it persists beyond 12 months or when there is a significant increase in aneurysm sac diameter.

The relationship of preoperative thrombus load and location to the development of type II endoleak and sac regression

Few studies have specifically correlated the amount of thrombus in the aneurysm sac and the presence of type II endoleaks (TIIE). This study examined the correlation of preoperative thrombus load and location to the incidence of TIIE and late sac regression. Prospectively collected data from 266 endovascular aneurysm repair (EVAR) patients were analyzed. Maximum thrombus thickness (MTT) and percentage of the circumference of the aortic wall lined by thrombus (thrombus-lined aneurysm circumference [TLAC]) were determined from preoperative computed tomography angiography (CTA) images at four levels: neck, maximum abdominal aortic aneurysms (AAA) diameter (zone B), zone A (between neck and zone B), and zone C (between zone B and aortic bifurcation). The number of aortic side branches (ASB) was also recorded (inferior mesenteric artery [IMA], accessory renals, lumbar, and middle sacral). Logistic regression was used to determine the association of TIIE with each variable. Thirty-three (12%) early and 32 (13%) late TIIE were noted at a mean follow-up of 22 months (range, 1-87 months). The mean MTT at zone B was 19.7 mm in patients without early TIIE and 18.8 mm in patients without late TIIE vs 14.4 and 17.2 mm in patients with early and late TIIE (P = .0137 and P = .444, respectively). The mean percentage of TLAC was 76% and 75% vs 65% and 64% in patients without vs with early and late TIIE (P = .0329 and P = .044, respectively). There was no correlation of early and late TIIE and thrombus location by zones. The IMA was patent in 7% and 7% of patients without early and late TIIE vs 16% and 15% with TIIE (P = .0367 and P = .077, respectively). The mean number of ASB in patients without (early and late) TIIE was 5.8 and 5.6 vs 5.8 and 7 with endoleak (P = .932 and P = .001, respectively). Univariate analysis showed the following variables decreased the incidence of early TIIE: MTT for zone B (odds ratio [OR] 0.79 for 5-mm increase; P = .014), MTT zone A (OR, 0.78; P = .028), MTT zone C (OR, 0.82; P = .043), and percentage of TLAC (OR, 0.88 for 10% increase; P = .036). For late TIIE: percentage of TLAC (OR, 0.88 for 10% increase; P = .048), and ASB (OR, 1.39 for each additional vessel; P = .001). A multiple regression model showed only ASB (OR, 1.34; P = .009) was a predictor for late TIIE. Four of five patients (80%) with late sac expansion vs 24 of 208 (12%) without expansion had late TIIE (P = .001). MTT, percentage of TLAC, number of ASB, and patent IMA influenced early TIIE; however, only the number of ASB influenced late TIIE.

RETRACTED: Hybrid Endovascular Repair in Aortic Arch Pathologies: A Retrospective Study

The aortic arch presents specific challenges to endovascular repair. Hybrid repair is increasingly evolving as an alternative option for selected patients, and promising initial results have been reported. The aim of this study was to introduce our experiences and evaluate mid-term results of supra aortic transpositions for extended endovascular repair of aortic arch pathologies. From December 2002 to January 2008, 25 patients with thoracic aortic aneurysms and dissections involving the aortic arch were treated with hybrid endovascular treatment in our center. Of the 25 cases, 14 were atherosclerotic thoracic aortic aneurysms and 11 were thoracic aortic dissection. The hybrid repair method included total-arch transpositions (15 cases) or hemi-arch transpositions (10 cases), and endovascular procedures. All hybrid endovascular procedures were completed successfully. Three early residual type-I endoleaks and one type-II endoleak were observed. Stroke occurred in three patients (8%) during the in-hospital stage. The perioperative mortality rate was 4%; one patients died post-operatively from catheter related complications. The average follow-up period was 15 ± 5.8 months (range, 1–41 months). The overall crude survival rate at 15 months was 92% (23/25). During follow-up, new late endoleaks and stent-raft related complications were not observed. One case (4%) developed a unilateral lower limb deficit at 17 days and was readmitted to hospital. In conclusion, the results are encouraging for endovascular aortic arch repair in combination with supra-aortic transposition in high risk cases. Aortic endografting offers good mid-term results. Mid-term results of the hybrid approach in elderly patients with aortic arch pathologies are satisfying.

Detection of Type II Endoleak After Endovascular Aortic Repair: Comparison Between Magnetic Resonance Angiography and Blood-Pool Contrast Agent and Dual-Phase Computed Tomography Angiography

This prospective study was designed to assess the diagnostic value of magnetic resonance angiography (MRA) with blood-pool contrast agent (gadofosveset) in the detection of type-II endoleak after endovascular aortic repair (EVAR). Thirty-two patients with aortic aneurysms who had undergone EVAR were included in this study. All patients were examined by dual-phase computed tomography angiography (CTA) as well as MRA with gadofosveset in the first-pass and steady-state phases. Two independent readers evaluated the images of CTA and MRA in terms of endoleak type II, feeding vessel, and image quality. Median follow-up-time after EVAR was 22 months (range 4 to 59). Endoleak type II was detected by CTA in 12 of 32 patients (37.5%); MRA detected endoleak in all of these patients as well as in another 9 patients (n = 21, 65.6%), of whom the endoleaks in 6 patients showed an increasing diameter. Most endoleaks were detected in the steady-state phase (n = 14). The decrease in diameter of the aneurysmal sac was significantly greater in the patients without a visible endoleak that was visible on MRA (P = 0.004). In the overall estimation of diagnostic accuracy, MRA was judged superior to CTA in 66% of all examinations. MRA with gadofosveset appeared superior to CTA, and has higher diagnostic accuracy, in the detection of endoleak after EVAR.

Hybrid treatment of isolated aortic arch aneurysms

This study sought to assess the feasibility and effectiveness of hybrid treatment of isolated aortic arch aneurysms. Between December 2000 and December 2006, we selected 14 patients affected by 14 isolated aortic arch aneurysms. All patients had involvement of the left subclavian artery, four of the innominate artery and four of the left carotid artery. All patients underwent intentional exclusion of the left subclavian artery and placement of a straight graft; four patients underwent supra-aortic vessel transposition and four underwent carotid-carotid bypass in one case combined with carotid-subclavian bypass. The procedures were planned with multislice computed tomography (MSCT), in some cases associated with virtual endoscopy. The follow-up was performed with MSCT angiography at 1, 3, 6 and 12 months and yearly thereafter. Immediate technical success was achieved in 100% of cases. There were four ischaemic attacks (three transient ischaemic attacks and one stroke). During follow-up (range 12-48, average 21 months), we observed two type-I endoleaks that were treated by endograft extension, in one case associated with supra-aortic vessel transposition, and two type-II endoleaks that were treated with embolisation. Hybrid treatment for aortic arch aneurysms is feasible and provides good short-term results, although it requires accurate planning. Further studies are needed to verify the long-term results.

Diagnostic sensitivity of multidetector-row spiral computed tomography angiography in the evaluation of type-ii endoleaks and their source: comparison between axial scans and reformatting techniques

After endovascular stent-graft placement, several complications may occur. Retrograde filling of the aneurysm (type-II endoleak) is the most common. To evaluate the accuracy, image quality, and interobserver agreement of multidetector-row spiral computed tomography angiography (MDCTA) in the diagnosis of type-II endoleak, by using various types of reformatting techniques in comparison to regular axial images. Twenty-four patients who had had endovascular repair of an infrarenal abdominal aortic aneurysm with stent graft were retrospectively studied. In 12 of 24 patients, a type-II endoleak was found. CT scans were obtained after intravenous administration of 130 ml of nonionic contrast material using a 4-6-ml/s flow rate. All patients were investigated with axial scans, multiplanar reconstruction (MPR), maximum intensity projection (MIP), shaded-surface display (SSD), and volume-rendering (VR) techniques. For each patient and for each reconstruction method, the image quality of the scans was scored as 0 for bad quality, 1 for poor quality, 2 for good quality, and 3 for excellent quality images. Two radiologists reviewed the CT images independently. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each reconstruction method, with the axial images as the reference method. Interobserver agreement and kappa value were also recorded. MPR showed the highest sensitivity (83% and 67% for observers 1 and 2, respectively), PPV (91% and 80% for observers 1 and 2, respectively), and NPV (85% and 71% for observers 1 and 2, respectively), whereas VR showed the highest specificity (92% for both observer 1 and 2). Reformatting techniques provide good-quality images; nevertheless, their efficacy in the study of type-II endoleak was found to be suboptimal in comparison to regular axial images. The MPR technique is probably the best choice in conjunction with axial images.

Endovaskuläre Therapie eines infrarenalen Aortenaneurysmas bei heterotopem Nierentransplantat

The indications for endovascular aortic aneurysm repair (EVAR) are mainly established in hostile abdomen, in patients with significant comorbidities which affect the general operability of the patient and, given the necessary infrastructure, also in ruptured aneurysm. Along to those, we present another possible indication in the presence of a kidney allograft in patients with aortic aneurysm. Based on a case report of aorto-biiliac stent-graft repair of an infrarenal aortic aneurysm in a patient with renal allograft, a systematic review of the literature was performed of all similar cases concerning surgical therapy in this constellation. EVAR was performed using an aorto-biiliac system (Zenith) Trifab, COOK) in a 61-year-old male patient 11 years after heterotopic renal allotransplantation in the right iliac fossa. Preoperative renal function was normal. Because the donor renal artery was anastomosed to the recipient's external iliac artery the stent-graft was implanted from the left common femoral artery to minimize temporary allograft ischemia. The intra- and postoperative course was uneventful with a follow-up of presently 12 months. A primary type-II endoleak (retroleak from a lumbar artery) is being treated conservatively so far with embolization being a future option. At present there are 15 cases of EVAR in renal allograft patients that have been reported, all of them being successful. All data existing in the literature reported to date as well as our own experience justify the first choice of EVAR in morphologically suitable cases. One major advantage of EVAR in this constellation is the avoidance of aortic cross clamping which poses the graft at risk of ischemia. Long-term results will be most important for definite assessment of EVAR. However, contrast media application during the operation and for CT surveillance should be considered as a major disadvantage.

Embolization-driven Occlusion of the Abdominal Aortic Aneurysmal Sac as the Basis of Prevention of Endoleaks in a New Swine Model

Objectives To assess the effect of a new polymer in embolization of endoleaks using an animal model. Methods A modified aortic stent-graft was placed in 20 pigs. Embolization was performed at the time of graft insertion with non-cytotoxic n-butyl-2-cyanoacrylate-metacryloxysulpholane and lipiodol (0.2:0.8ratio, 2 ml). Angiography, scanning electron microscopy and immuno-histochemistry were obtained at day 0, 1 week and 3 months. Results In control animals both type I and II endoleaks were demonstrated. In treated animals, neither type-I nor type-II endoleaks were observed and a fibro-proliferative response was demonstrated within the aneurysm thrombus. Conclusions Host vascular responses govern the fate of the excluded aneurysm. Embolization of the sac and feeding arteries with non-cytotoxic glue sealed all occlusions by stimulating a massive restenosis-like process.

Endovascular Abdominal Aortic Aneurysm Repair outside a Tertiary Referral Centre: Feasibility and Impact upon Workload

In the UK, the majority of endovascular abdominal aortic aneurysm repairs (EVAR) are carried out in tertiary referral centres. We studied the feasibility and impact upon workload of an endovascular programme introduced into a district general hospital. Data was collected prospectively on ail patients considered for EVAR since the inception of the programme in April 1999. Evaluation was by contrast enhanced CT scan followed by angiography if potentially suitable for EVAR. We recorded eligibility for EVAR. reasons for exclusion and the outcome of all patients irrespective of the mode of repair. Ninety patients were assessed over a 26-month period, nine of which did not complete the evaluation process. Sixty patients had one or more morphological features that precluded EVAR. Twenty-one patients were eligible for EVAR (26%). of which eighteen proceeded to EVAR. one awaits EVAR and two were below the treatment threshold (< 5.5 cm). Seventeen had successful aneurysm exclusion and one required immediate conversion. One patient died within 30 days from gastrointestinal haemorrhage. There was one type-II endoleak at 1 month and to date we have encountered no ruptures or aneurysm-related deaths. Of the remaining 60 patients. 29 have proceeded to elective and 8 to urgent open repair with 2 deaths within 30 days in each group. EVAR is feasible outside tertiary referral centres and satisfactory early results can be achieved. An endovascular programme has important implications upon radiological and surgical workload. The operative mortality of patients undergoing open aortic repair remains acceptable following the introduction of an endovascular service into a district general hospital.

Endovascular abdominal aortic aneurysm repair outside a tertiary referral centre: feasibility and impact upon workload

In the UK, the majority of endovascular abdominal aortic aneurysm repairs (EVAR) are carried out in tertiary referral centres. We studied the feasibility and impact upon workload of an endovascular programme introduced into a district general hospital. Data was collected prospectively on all patients considered for EVAR since the inception of the programme in April 1999. Evaluation was by contrast enhanced CT scan followed by angiography if potentially suitable for EVAR. We recorded eligibility for EVAR, reasons for exclusion and the outcome of all patients irrespective of the mode of repair. Ninety patients were assessed over a 26-month period, nine of which did not complete the evaluation process. Sixty patients had one or more morphological features that precluded EVAR. Twenty-one patients were eligible for EVAR (26%), of which eighteen proceeded to EVAR, one awaits EVAR and two were below the treatment threshold (<5.5 cm). Seventeen had successful aneurysm exclusion and one required immediate conversion. One patient died within 30 days from gastrointestinal haemorrhage. There was one type-II endoleak at 1 month and to date we have encountered no ruptures or aneurysm-related deaths. Of the remaining 60 patients, 29 have proceeded to elective and 8 to urgent open repair with 2 deaths within 30 days in each group. EVAR is feasible outside tertiary referral centres and satisfactory early results can be achieved. An endovascular programme has important implications upon radiological and surgical workload. The operative mortality of patients undergoing open aortic repair remains acceptable following the introduction of an endovascular service into a district general hospital.

Initial Results of Endovascular Repair of Abdominal Aortic Aneurysms with a Self-expanding Stent-Graft

This study was performed to evaluate the authors' experience with the endovascular treatment of abdominal aortic aneurysm (AAA) with use of a self-expanding nitinol stent covered with a polyester fabric device and to report the implant's technical features, the immediate results, and the outcome 30 days after device implantation. From June 1997 to December 2001, we admitted 169 patients diagnosed with AAA. Of these, 134 were suitable to undergo endovascular repair with use of the Talent stent-graft. In one patient, it was technically impossible to proceed with the implantation procedure. Therefore, a total of 133 patients were treated with use of this technique (78.7%). The average age was 70.7 years (range, 52-88 y). There were 119 men and 14 women. Computed tomographic follow-up was done between the 15th and 30th postoperative days. The stent-grafts were successfully implanted in all 133 patients. Complications during the procedure included three type-I endoleaks (2.3%) and four iliac artery ruptures (3.0%), which were effectively treated by means of aortic or iliac extension grafts, respectively. The average surgical time was 2.92 hours (from 1.67 h to 7 h). Of the stent-grafts used, 125 were bifurcated (94.0%), two were straight tube grafts (1.5%), and six were conical aortouniiliac grafts (4.5%). Custom-made grafts were used in 62 patients (46.6%) and standard grafts were used in 71 (53.4%). Suprarenal fixation was performed in 117 patients (88%). One female patient developed a serious pulmonary embolism. Eight patients (6.0%) developed serious systemic inflammatory syndrome; two died of disseminated intravascular coagulopathy. There were two additional deaths, one from refractory shock and one suddenly from an unknown cause (total mortality rate, 3.0%). During the postoperative period, 70.3% of the patients developed mild fever (37.6 degrees C-38.9 degrees C). The average length of stay in the intensive care unit was 1.3 days (ranging from 1 d to 12 d) and the total hospitalization time was 4.2 days. Six type-II endoleaks were observed: two were corrected by video laparoscopy-assisted inferior mesenteric artery interruption and the other four were clinically followed up. The exclusion of AAA by endovascular techniques with use of the Talent device was possible in the majority of cases with a low incidence of complications. The most common serious postprocedural complication was systemic inflammatory syndrome.

Type-II endoleaks following endovascular AAA repair: preoperative predictors and long-term effects.

To determine the significance of persistent type-II endoleaks and whether they can be predicted preoperatively in patients with abdominal aortic aneurysms (AAA). The charts of all AAA patients treated with the AneuRx stent-graft at a single center from 1996 to 1998 were reviewed. Patients with <12-month follow-up or type-I endoleaks were excluded. The presence or absence of type-II endoleaks was determined from duplex imaging and computed tomographic angiography. Three groups were identified and compared: 16 patients with persistent type-II endoleaks (PE), 14 patients with transient type-II endoleaks (TE), and 16 patients with no endoleak (NE). The groups did not differ with regard to age, preoperative comorbidities, follow-up time, and AAA neck diameter and length. AAA diameters were 57.1 +/- 9.0 mm for NE, 63.4 +/- 11.4 mm for TE, and 55.6 +/- 4.2 mm for PE. The inferior mesenteric artery (IMA) was patent in 5 (31%) NE patients, 6 (43%) TE patients, and 13 (81%) PE patients (p < 0.01). The number of patent lumbar arteries visualized preoperatively was 0.5 +/- 1.0 in NE, 1.3 +/- 0.8 in TE, and 2.4 +/- 0.6 in PE (p < 0.0001). Patent IMAs (RR 0.82, p < 0.01) and >2 lumbar arteries (RR 0.40, p < 0.0001) were identified as independent preoperative risk factors for persistent endoleaks. There were no changes in mean diameter or volume in aneurysms with persistent endoleaks. No adverse clinical events were related to the presence of type-II endoleaks, but there was no decrease in aneurysm size in patients with persistent type-II leaks. Patients with a large, patent IMA, or >2 lumbar arteries on preoperative CT angiography are at higher risk for persistent type-II endoleaks.