Management of Type IA Endoleak After EVAR by Explantation or Custom Made Fenestrated Endovascular Aortic Aneurysm Repair

Doumenc, Benoît; Mesnard, Thomas; Patterson, Benjamin O.; Azzaoui, Richard; Préville, Agathe De; Haulon, Stéphan; Sobocinski, Jonathan

doi:10.1016/j.ejvs.2020.10.033

Cited by 23 publications

(16 citation statements)

References 25 publications

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“…For patients with significant co-morbidities and an enlarged sac with a maximum diameter less than 7.5 cm, we employed ARAFAT. Our results mimic Doumenc et al (12) finding's that explantation and endovascular management, hybrid endovascular repair and ARAFAT can be achieved in high deliberate practice volume centres with satisfactory results. All our re-interventions had aortic sac size greater than 6 cm at the time of their primary EVAR with more than three modular stent graft components.…”

Section: Discussionsupporting

confidence: 90%

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: Discussionsupporting

confidence: 90%

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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“…Management of these endoleaks remains challenging whether by open or endovascular surgery. 1,2,3 Open surgery with complete or partial graft extraction has been described but carries a high risk of mortality and morbidity in a group of patients that are already frail. 3,4 Besides endostapling, endovascular repair is most often complex and requires advanced skills since proximal extension with a simple tube is rarely an option, and as most grafts from the index procedure are already positioned at the level of the renal arteries, any new repair should include the visceral aorta.…”

Section: Discussionmentioning

confidence: 99%

“…FEVAR after failed EVAR has been described with good success rate. 2,3,8 However, the presence of a previous graft makes this technique much more challenging because of the difficulty of rotating the graft introducer inside the previous EVAR limb, as well as the need to catheterize the target vessels through the struts of the suprarenal bare stent. In the two largest series published by Katsargyris et al and Martin et al, both groups described technical difficulties related to poor torquability of the fenestrated device which was responsible for rotational misalignment and loss of target vessels in some cases.…”

Section: Discussionmentioning

confidence: 99%

“…These endoleaks are often challenging to treat and need complex open surgical and endovascular skills like fenestrated (FEVAR) or branched (BEVAR) repairs. 2 There are no clear guidelines on how to manage type Ia endoleaks. Many factors are considered when choosing a treatment strategy: anatomic features for endovascular repair and physiologic characteristics for open surgery.…”

Section: Introductionmentioning

confidence: 99%

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Treatment of a type Ia endoleak following EVAR using a custom-made inner branch device.

Montessuit

2021

Vascular

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Objectives We represent two cases of late proximal type I endoleak following EVAR with aneurysm expansion that were treated with a custom-made graft with inner branches. Methods Two patients of 87 and 82 years old were operated by EVAR 6 and 8 years ago for abdominal aortic aneurysm. Both had proximal type I endoleak with aneurysm sac expansion. Open surgery had a high risk, and a proximal aortic extension with a simple aortic cuff was not possible neither because previous EVAR grafts were already at the level of the renal arteries. A custom-made endograft with inner branches was planned as a fenestrated graft was not technically possible. Results We successfully treated both patients using a custom-made graft with four inner branches from Jotec (Cryolife, Kennesaw, GA). Three months’ follow-up CT scan did not show any endoleaks. All target vessels were patent with good conformability of the bridging stents. Conclusion The treatment of proximal type I endoleak using inner branches’ endografts is feasible. This novel technology might broaden the indications for complex aortic repair in a group of patients where fenestrated endografts are not possible.

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“…Die nach der Meinung der Autoren beste Methode zur Behandlung eines Typ-Ia-Endoleaks stellt eine signifikante Verlängerung des Stentgrafts nach proximal unter Verwendung einer 2‑ bis 4fach fenestrierten tubulären Prothese dar [ 15 ]. Hier kann speziell bei initial grenzwertig kurzen Hälsen eine sichere Landung in einem gesunden Aortensegment erfolgen und – im Fall der vierfach fenestrierten Prothese – steht auch eine Landezone für eine allfällig später notwendige noch weitere proximale Verlängerung mit weiteren Stentgrafts zur Verfügung.…”

Section: Typ-i-endoleakunclassified

Endovaskuläre Aortenreparatur bei Endoleaks

Hauck

Schernthaner²,

Dachs

et al. 2022

Radiologie

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ZusammenfassungSämtliche Patienten nach endovaskulärer Versorgung eines Aortenaneurysmas bedürfen einer regelmäßigen Nachkontrolle, zumeist in jährlichem Abstand. Der kontrastmittelverstärkte Ultraschall und die Computertomographie-Angiographie (CTA) sind die wichtigsten diagnostischen Modalitäten für die Erkennung von Endoleaks. Die (CTA) erlaubt eine bessere Unterscheidung der verschiedenen Endoleak-Typen. Sogenannte Hochdruck-Endoleaks (Typ I und Typ III) stellen, wenn sich nicht kurzzeitig ein Spontanverschluss zeigt, eine absolute Indikation zur Nachbehandlung dar. Typ-II-Endoleaks weisen in der Mehrzahl einen benignen Verlauf auf. Wenn kein Wachstum des Aneurysmasacks erfolgt, kann eine Nachkontrolle im gewohnten Intervall durchgeführt werden. Typ-II-Endoleaks mit assoziiertem Wachstum des Aneurysmasacks können durch Embolisation der verantwortlichen Gefäße behandelt werden. Ob eine Behandlung immer durchgeführt werden muss, ist umstritten. Eine Behandlungsindikation von einem Typ-II-Endoleak mit wachsendem Aneurysmasack ist jedoch gegeben, wenn durch eine Verkürzung des Aneurysmahalses ein sekundäres Typ-I-Endoleak droht. Typ-I-Endoleaks stellen die Hauptlimitation der Stentgraft-Therapie dar. Die beste Prävention eines Typ-I-Endoleaks ist die Bereitstellung einer adäquaten proximalen Landezone. Dies kann durchaus bedeuten, dass fenestrierte Stentgrafts verwendet werden müssen. Die Verwendung von Schrauben oder anderen Fixationsinstrumenten zur sicheren Behandlung auch kurzer Hälse ist derzeit noch in der Studienphase.

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Management of Type IA Endoleak After EVAR by Explantation or Custom Made Fenestrated Endovascular Aortic Aneurysm Repair

Cited by 23 publications

References 25 publications

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

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

Treatment of a type Ia endoleak following EVAR using a custom-made inner branch device.

Endovaskuläre Aortenreparatur bei Endoleaks

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