ENDOLEAKSENDOLEAKSType I, IIIType I, III

Trellopoulos GeorgiosTrellopoulos GeorgiosVascular surgeonVascular surgeon

Gen. Hosp. “G. Papanikolaou”, ThessalonikiGen. Hosp. “G. Papanikolaou”, Thessaloniki

Endoleak‘Blood flow outside thelumen of the endoluminal graft but within the aneurysm sacor adjacent vascularsegment treated by thegraft’.

White 1997

Classification of Endoleak

1a Proximal fixation site1b Distal fixation site1c Iliac occluder

Type 1 Graft-related(fixation sites)

Classification of Endoleak

Type 2 Retrograde branch flow

2a Inferior mesenteric

2b Lumbar

Classification of Endoleak

Type 3 Graft-related (device integrity)

Type 3a Disjunction of modular partsType 3b Fabric tear

Classification of Endoleak

Type 4 Graft-relatedFabric Porosity

Valid diagnosis within 30 daysafter operation only

Endotension

‘Persistent or recurrent pressurisation of the aneurysm sac (with or without endoleak)’

Gilling-Smith 1999

Expanding sac

Diagnosis CT angiographyCT angiography MRAMRA DSADSA TriplexTriplex

CT technique•Maximum 3mm thickness

•Two acquisitions •Arterial and 5 minute delayed •Diaphragm to groins

Indications

For 2nd interventionRisk factors for rupture – Multivariate analysis

Risk ratio PRisk ratio PLast diam. AAA 1.057 0.0028Last diam. AAA 1.057 0.0028Proximal Type 1 3.998 0.0266Proximal Type 1 3.998 0.0266Midgraft Type 3 7.474 0.0024Midgraft Type 3 7.474 0.0024Migration 5.335 0.0156Migration 5.335 0.0156

Independent risk factors for rupture

Management Type I, III endoleaksManagement Type I, III endoleaksStrategyStrategy

Conservative ?Conservative ? BallooningBallooning Palmaz stentingPalmaz stenting CuffCuff Stent-graftStent-graft EmbolizationEmbolization Endostapling ?Endostapling ?

Type 1a

Type 1b

Ballon dilatation

+/- Palmaz stent

Embolization

? Extra-luminal banding?

Type 1 Endoleak (no migration)

Balloon dilatation

Embolization

ManagementType 1 Endoleak (with migration)

Type 1b

Extension cuff

+/- embolization

Covered stent

+/- embolization

Type 1a

ManagementType 3 Endoleak (with migration)

Cover stentCover stentConversion to aorto-uniliac with fem-femoral by-passConversion to aorto-uniliac with fem-femoral by-pass

Type 3a

Covered stent

CasesCases

Endoleak type IaEndoleak type Iaconservative treatmentconservative treatment

CT examination after 9 days – endoleak Ia

Preoperative CT: 90% angulation of the proximal neck

Endoleak type IaEndoleak type Iaconservative treatementconservative treatement

CT examination 14 months after: no endoleak

Preoperative CT: endoleak type Ia

Endoleak type IaEndoleak type Iacuffcuff

CT examination after 11 days

Endoleak type IaEndoleak type Iaembolizationembolization

1st CT examination2rd CT, after 4 days: endoleak Ia

CT examination after embolization

Final CT, 5 days after: no endoleak

Endoleak type IbEndoleak type Ibiliac extensioniliac extension

Preoperative CT & DSA images: endoleak Ib

Endoleak type IbEndoleak type Ibiliac extensioniliac extension

CT examination after 3,5 months: no leakage

Endoleak type IbEndoleak type Ibiliac extensioniliac extension

CT examination after 2 years and 9 months: endoleak from the right limbFinal CT after placement of iliac extension: no leakage

Endoleak type Ia, Ib, IIEndoleak type Ia, Ib, II

Preoperative CT: endoleak type Ia, II

Endoleak type Ia, Ib, IIEndoleak type Ia, Ib, II

2nd DSA examination, after 10 days: Occlusion of the type Ia

CT examination after 10 days: persistence of the II endoleak

CT examination after 7 months: persistence of endoleak type II

DSA examination, after CT: endoleak type Ib

Final CT examination after 1 month: no leakage

Endoleak type IbEndoleak type Ibconversion to openconversion to open

Preoperative CT: acute AAA

CT & DSA images 10 days after the procedure: Endoleak type Ib

Endoleak type IbEndoleak type Ibconversion to openconversion to open

CT examination 3 months after extension placement

4 years after the procedure, migration of the left limb

EUROSTAR 2006EUROSTAR 2006in 2846 patientsin 2846 patients

Type I endoleak Type I endoleak ~ 2% in 12 months~ 2% in 12 months

Type III endoleak ~ 1% Type III endoleak ~ 1%

Treated by transfemoral approach: 60%Treated by transfemoral approach: 60%

Secondary intervention in 8,7% at 12 months Secondary intervention in 8,7% at 12 months after procedure. 1/3 of them for endoleak type I after procedure. 1/3 of them for endoleak type I & III& III

EUROSTAREUROSTAR Group C (diam > 6,4cm)Group C (diam > 6,4cm) Angulation of the proximal neckAngulation of the proximal neck Diameter of the proximal neckDiameter of the proximal neck

Type I endoleak at completion angiography was Type I endoleak at completion angiography was 9,9% vs 3,7 in group A (diameter < 5,5)9,9% vs 3,7 in group A (diameter < 5,5)

Risk factors and prevention

• Short or angulated infrarenal aortic neck are the most significant preoperative risk factors for type I endoleak

• Neck length < 20mm and diameter > 28mm can lead to an endograf migration and endoleak

• Aortic neck dimension and quality of proximal and distal fixation site are the most critical factors for prevention of endoleak

•Two of three endoleaks that are seen at the time of the discharge seal during the first month after the procedure

Close proximity of the Close proximity of the distal end of the distal end of the stent graft to the stent graft to the iliac bifurcation iliac bifurcation seems to provide seems to provide stability against stability against migration.migration.

The importance of iliac The importance of iliac fixation in prevention of fixation in prevention of stent graft angulation. stent graft angulation.

Christofer Zarins et al JVS 2006

27% of the patients 27% of the patients required secondary required secondary procedures (98 procedures (98 procedures).procedures).87% of them were 87% of them were treated endovascularly.treated endovascularly.

(8 years experience)(8 years experience)

J P Bequemin et al JVS 2004

ConclusionsConclusions1. It is critical to select the appropriate patient1. It is critical to select the appropriate patient Neck length > 10mmsNeck length > 10mms Neck diameter < 30mmsNeck diameter < 30mms Neck angulation < 75 degreesNeck angulation < 75 degrees Oversize by 20%Oversize by 20%

2. Security of the proximal graft fixation is the most 2. Security of the proximal graft fixation is the most important factor in preventing acute and late type I important factor in preventing acute and late type I endoleaks. endoleaks. It is recommended that the endograft It is recommended that the endograft is placed as close to the renal arteries as possible is placed as close to the renal arteries as possible and extended to the hypogastric arteriesand extended to the hypogastric arteries

ConclusionsConclusions

3. 60 – 85% of the type I and III endoleaks 3. 60 – 85% of the type I and III endoleaks can be treated with endovascular can be treated with endovascular approach. approach.

4. 4. Critical point: the surveillance of the Critical point: the surveillance of the patients using CTApatients using CTA

Thank you for your attention!