Surgical conversion with graft salvage as a definitive treatment for persistent type II endoleak causing sac enlargement

Abstract

Objective: The goal of this study was to present open surgical conversion with graft salvage or "semiconversion" as a definitive and safe treatment for untreatable and persistent type II endoleaks causing sac enlargement after endovascular aneurysm repair. Methods: Between January 2001 and December 2014, 25 of 1623 endovascular aortic repair (EVAR) patients were selected as candidates for open semiconversion. The indication was persistent type II endoleak in 13 patients (12 of whom received previous attempts of embolization), type I and II endoleak in 2 patients, and sac growth without imaging evidence of endoleak in the other 10. After the infrarenal aorta was prepared (via a retroperitoneal access, whenever possible), the technique consisted of performing a banding of the neck with Teflon (DuPont, Wilmington, Del), a sacotomy to remove the thrombus or the hygroma, or both, and then suturing all of the feeding vessels that were found. Proximal and distal fenestrations were performed to avoid sac repressurization. Results: The semiconversion was performed after a mean of 74 months after the initial EVAR. The mean aneurysm size at the time of the EVAR was 6.0 cm (range, 5.0-9.5 cm), and the mean aneurysm size at the time of the semiconversion was 7.7 cm (range, 5.5-11.5 cm). The overall aneurysm size increase was 38%, and the average growth rate was 8.2% per year. One patient had a stable aneurysm size but was treated because of an emergency condition. Technical success was 100%, with resolution of the endoleak and no perioperative deaths. Four cardiac deaths were registered at 12, 26, 30, and 60 months (mean follow-up, 42 months; range, 1-80 months). Conclusions: Graft salvage appears to be a valid option compared with open repair when considering treatment of persistent type II endoleak. This case series shows that semiconversion is a safe and effective treatment for otherwise untreatable type II endoleak. (J Vasc Surg 2015;62:1437-41.)

Outcomes of Late Open Conversion after Endovascular Abdominal Aneurysm Repair

“…Moulakakis et al reported that type Ia and Ib endoleaks occurred because of main body and limb dislocations during ligation of the culprit vessels. 19) The recurrence of the endoleak has not been reported, 18,20) but ligating all side branches as much as possible is necessary. Additionally, continuously monitoring new onset endoleaks and infections is necessary.…”

Collected Transatlantic Experience From the PERICLES Registry: Use of Chimney Grafts to Treat Post-EVAR Type Ia Endoleaks Shows Good Midterm Results

“…[17][18][19] The possibility of performing a partial conversion or entirely sparing the endograft has been shown to reduce the risk of the open procedure, 20 but endovascular treatment, when feasible, certainly represents a better option for this high-risk population. [21][22][23] Cuffs are a reasonable approach to treat distal migration with a residual infrarenal neck, but different strategies are necessary when the graft is still in place. Embolization with Onyx and/or coils has been described as an effective option in selected cases.…”

An Institution-Wide Algorithm for Treatment of Type II Endoleak Following Endovascular Aneurysm Repair (EVAR)

“…34,35 However, these studies did not exclude other endoleak types nor did they require endovascular coil or Onyx embolization attempts prior to open intervention. Mangialardi et al 36 described 12 patients who underwent open repair for the treatment of pT2EL following failed endovascular interventions; however, banding of the proximal aorta with Teflon (The Chemours Co., Wilmington, DE) for stability was performed prior to sac imbrication around the endograft. More recently, Metrias et al 11 proposed endoaneurysmorrhaphy with stent graft preservation as an effective treatment of pT2EL with sac expansion following EVAR; however, not all patients in this series underwent initial endovascular attempts before proceeding with open conversion.…”