Management of Concealed Type IV Endoleak and Aortic Sac Hygroma by Prone ContrASt EnHancement Computed Tomography Angiography

Sultan, Sherif; Acharya, Yogesh; Atteia, Emad; Hynes, Niamh

doi:10.1016/j.avsg.2020.11.039

Cited by 1 publication

(11 citation statements)

References 38 publications

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“…All our patients were followed-up with duplex ultrasonography (DUS) and plain film abdomen every six months. Patient with continuous sac expansion without detection of EL through conventional supine computed tomography angiography (CTA) underwent a Prone contrASt enHanced computed tomography Angiography (PASHA), a multiphase time-resolved four-phase positional (prone) CTA protocol for detection and classification of concealed ELs ( 7 ). The PASHA protocol enhanced the degree of contrast infiltration into the aortic sac when microleaks were present, which helped us to plan the re-intervention strategy.…”

Section: Methodsmentioning

confidence: 99%

“…The PASHA protocol enhanced the degree of contrast infiltration into the aortic sac when microleaks were present, which helped us to plan the re-intervention strategy. PASHA diagnosed all cases of type IIIb EL that were previously classified as concealed Type V EL in the context of continuous sac enlargement ( 7 ).…”

Section: Methodsmentioning

confidence: 99%

“…Our decision-making has been influenced by several factors, including the mode of endograft failure, aneurysm sac size and patient fitness for surgery. Our ability to make informed decisions on the mode of failure evolved after we spearheaded the PASHA CTA protocol to accurately differentiate between different types of ELs and aortic sac hygromas ( 7 ). Aortic sac hygromas with the Hounsfield unit (HU) < 25 and an associated sac size greater than 7.5 cm indicate aortic aneurysm sac failure and a loss of the ability of the aortic wall to remodel ( 7 ).…”

Section: Methodsmentioning

confidence: 99%

“…Our ability to make informed decisions on the mode of failure evolved after we spearheaded the PASHA CTA protocol to accurately differentiate between different types of ELs and aortic sac hygromas ( 7 ). Aortic sac hygromas with the Hounsfield unit (HU) < 25 and an associated sac size greater than 7.5 cm indicate aortic aneurysm sac failure and a loss of the ability of the aortic wall to remodel ( 7 ). In cases with no defined type I, II or III ELs, and HU was less than 25, a diagnosis of expanding aortic hygroma was confirmed, and aneurysmorrhaphy was performed.…”

Section: Methodsmentioning

confidence: 99%

“…They expand slowly without evidence of EL forming a phlegmon with jellylike consistency around the endograft. They have radiodensity less than 25 Hounsfield units (HU) and are most commonly associated with polyester endografts (7)(8)(9)(10)(11). Diagnosis of aortic sac hygromas was neither feasible nor accurate previously; however, newer imaging techniques will identify them.…”

Section: Aortic Sac Hygroma and Double-breastingmentioning

confidence: 99%

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Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned

et al. 2022

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ObjectivesWe aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation.MethodsWe performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV).ResultsForty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure.ConclusionsOur re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%