SIR RFS Case Series: A Complex Endoleak Repair

8/11/2019 SIR RFS Case Series: A Complex Endoleak Repair

http://slidepdf.com/reader/full/sir-rfs-case-series-a-complex-endoleak-repair 1/17

A COMPLEX ENDOLEAK RE

Resident(s): Ihab Akladious, MDAttending(s): Raj Pyne, MD

Program/Dept(s): Rochester General Hospital, Rochester, NY

Originally Posted:



CHIEF COMPLAINT & HPI

History of Present Illness

71 y/o female with history of thoracic and abdominal aortic aneurysms s/p combinedand EVAR with debranching procedure to reconstitute flow to the mesenteric arterikidneys (common graft from aortic bifurcation to right renal artery, proper hepatic aSMA, and second graft from right common iliac artery to left renal artery), presentspost-operatively for surveillance CT examination



RELEVANT HISTORY

Past Medical History Hypertension

Aortic valve stenosis

Thoracic aortic aneurysm

Abdominal aortic aneurysm

Past Surgical History Aortic valve replacement

TEVAR, EVAR and debranching procedure

Medications Aspirin, simvastatin, losartan-HCTZ, ipratropium nasal spray

Allergies NKDA



DIAGNOSTIC WORKUP – CTA 5 MONTHS AFTER

A: Coronal image from CT angiogram shows aType II endoleak (arrow) within the nativeaneurysm sac adjacent to both thoracic andabdominal endografts

B and C: Sagittal and axial images from CT angiogram shendoleak with retrograde filling from the celiac trunk (arr

A B

C



DIAGNOSTIC WORKUP – CTA 5 MONTHS AFTER

Delayed phase axial image from CT angiogram

shows the prominent complex Type II endoleak with

a prominent right lumbar artery also providing

retrograde flow and contributing to the endoleak

(arrow).



DIAGNOSIS

Complex type II endoleak involving the descending aorta extending from the levdiaphragmatic hiatus to the takeoff of the celiac axis, a result of retrograde fillindebranching grafts via the celiac trunk, as well as the lumbar arteries.



QUESTION

Which type of endoleak is related to an inadequate seal at the ends of a stent graon one of the following answers)

A. Type I

B. Type II

C. Type III

D. Type IV E. Type V



CORRECT!


A. Type I. This is a leak at the graft ends from an inadequate seal.

B. Type II. This is an endoleak that occurs when the aneurysm sac is filled by a branch ve

C. Type III. This type of endoleak is caused by graft failure.

D. Type IV. This type of endoleak is caused by graft porosity.E. Type V. No discernable endoleak is present but the aneurysm size continues to incre

(endotension).

CONTINUE WITH CASE



SORRY, THAT’S INCORRECT.


A. Type I. This is a leak at the graft ends from an inadequate seal.

B. Type II. This is an endoleak that occurs when the aneurysm sac is filled by a branch ve

C. Type III. This type of endoleak is caused by graft failure.

D. Type IV. This type of endoleak is caused by graft porosity.E. Type V. No discernable endoleak is present but the aneurysm size continues to incre

(endotension).

CONTINUE WITH CASE



INTERVENTION

After interdisciplinary discussionwith vascular surgery, the plan

was to attempt to repair this

endoleak using an endovascular

approach, through the existing

debranching grafts.

Therefore, knowing the

angiogram would be a “maze” of

vessels, a map with the proposedpathway was drawn as a guide

prior to the procedure.

Endoleak

Pre-procedural drawing with proposed pathway through graft viaretrograde common hepatic artery to celiac trunk.

Initial flush aortic angiogram with

Graft from aorticbifurcation to rightkidney, proper hepaticartery (highlightedpink), and SMA

Graft from rightcommon iliacartery to leftkidney

Liver

Rt kidney Lt kidney

GDA

Endoleak



INTERVENTION – PRE-EMBOLIZATIONANGIOGRAPHY

Magnified view demonstrating the vascular anatomy. Superselective angiography with a microcathe

placed in the celiac trunk clearly shows the Tyendoleak (arrows).



INTERVENTION – POST-EMBOLIZATIONANGIOGRAPHY

Post-embolization angiography demonstratecomplete embolization of the large aneurysmand the celiac trunk after placement of multipdetachable framing coils and long detachable(arrows) as well as n-BCA glue liquid embolicThere were multiple unsuccessful attempts tothe feeding lumbar arteries, which were nevevisualized. Repeat angiography after 5 minut

confirmed no endoleak filling.



SUMMARY & TEACHING POINTS

•Large complex Type II endoleak in a patient status post TEVAR and EVAR witprocedure to reperfuse her mesenteric vessels

• Two sources were identified for the endoleak, including the celiac artery as wlumbar arteries

• Proper planning was essential given the complicated anatomy following theand a map drawn based off of the CTA was invaluable in navigating to the or

endoleak at the celiac trunk• Technically successful endovascular endoleak repair through the debranchin

retrograde approach from the proper hepatic artery with successful coil andembolization of the endoleak as well as the celiac trunk feeding vessel



QUESTION

How are type II endoleaks typically repaired?

A. Placement of extension endograft modules adjacent to the endoleak

B. Placement of transmural fixation devices to anchor the endograft to th

C. Trans-arterial/trans-lumbar embolization of the endoleak cavity and fe

D. Open surgical repair



CORRECT!






CONTINUE WITH CASE



SORRY, THAT’S INCORRECT.






CONTINUE WITH CASE



REFERENCES

Rosen R.J., Green R.M. Endoleak Management following Endovascular Aneurysm Repair. J Vasc Inte2008; 19(6):S37-S43

Stavropoulos S.W., Charagundla S.R. Imaging techniques for detection and management of endoleendovascular aortic aneurysm repair. Radiology. 2007;243 (3): 641-55

Bashir M.R., Ferral H. et-al. Endoleaks after endovascular abdominal aortic aneurysm repair: managstrategies according to CT findings. AJR Am J Roentgenol. 2009;192 (4): W178-86

Hong C., Heiken J.P. et-al. Clinical significance of endoleak detected on follow-up CT after endovascabdominal aortic aneurysm. AJR Am J Roentgenol. 2008;191 (3): 808-13

Date post:	02-Jun-2018
Category:	Documents
Upload:	sirrfs
View:	228 times
Download:	0 times

SIR RFS Case Series: A Complex Endoleak Repair

Documents