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Persistent Type I Endoleak after Endovascular Treatment with Chimney Technique.

ABSTRACT: Thoracic endovascular aortic repair (TEVAR) is increasingly used in the treatment of acute type B aortic dissection. Type Ia endoleaks are a common complication of the procedure, but its clinical significance and the best treatment strategy remain poorly defined. We present a case of a type Ia endoleak following TEVAR in the treatment of acute type B aortic dissection. Chimney technique approach was used in an attempt to seal the endoleak. Although technical success was suboptimal, the patient remained clinically stable and event free. Data regarding the natural course and management of type Ia endoleaks following TEVAR for aortic dissection are sparse. Future research is required to establish the clinical and technical determinants of the need to treat these endoleaks and the best treatment strategy.

SUBMITTER: Azevedo AI

PROVIDER: S-EPMC5028720 | biostudies-literature | 2016

REPOSITORIES: biostudies-literature

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Persistent Type I Endoleak after Endovascular Treatment with Chimney Technique.

Azevedo Ana Isabel AI Braga Pedro P Rodrigues Alberto A Ferreira Nuno N Fonseca Marlene M Dias Adelaide A Gama Ribeiro Vasco V

Frontiers in cardiovascular medicine 20160920

Thoracic endovascular aortic repair (TEVAR) is increasingly used in the treatment of acute type B aortic dissection. Type Ia endoleaks are a common complication of the procedure, but its clinical significance and the best treatment strategy remain poorly defined. We present a case of a type Ia endoleak following TEVAR in the treatment of acute type B aortic dissection. Chimney technique approach was used in an attempt to seal the endoleak. Although technical success was suboptimal, the patient r ...[more]

PMID: 27703967

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Project description:In endovascular aortic aneurysm repair (EVAR), proximal type 1A endoleaks can occur as a result of hostile neck anatomy or over- or undersizing of the endograft. As the current standard is based on the diameter or average of the short and long axes in a central lumen reconstruction image, it can falter in irregularly shaped aortic necks. An alternative method is circumference-based, therefore minimizing the measurement error. In this study we aimed to assess the degree of discrepancy between both methods and the association of this discrepancy with the occurrence of endoleak type 1A.All patients with early (<30 days post-operative) endoleak type 1A after elective EVAR at our center between 2004 and 2016 were identified for a retrospective case-control study. Control patients were matched based on hostile neck anatomy, such as calcification, thrombus, reverse taper, and ?-angulation. The aortic neck diameter was measured using the traditional, diameter-based method as well as an alternative method, based on the circumference of the aortic neck.In 482 EVAR patients, 18 early endoleak type 1A cases were found (3.9%). After exclusion, 12 cases remained and 48 matching controls were found. No significant differences were found between the two measuring methods at any level below the renal arteries. The inter-observer variability was significant for the D(mean) (0.4 ± 1.69 mm, P = .02) and was larger than the D(circ) method (-0.1 ± 1.03 mm, P = .35). In only four out of 12 cases the endograft size was 10-20% larger than the D(mean) and D(circ) measurements. The differences between the diameter of the D(mean) and D(circ) and the chosen endograft were smaller for the case group (-8 ± 25.6% and -7 ± 24%) than for the control group. (-12.4 ± 12.4% and -11 ± 10.7%).The difference between the D(mean) and D(circ) methods for aortic neck measurement was not large enough to play a significant role in the incidence of endoleak type 1A. Inadequate oversizing and considerable ?-angulation of the aortic neck may have been the cause of endoleak type 1A in this population. Robust and well-investigated sizing methods are paramount for accurate endograft sizing and prevention of endoleak type 1A. Therefore the lack of studies in this field and a sizeable inter-observer variability do not justify the widespread reliance on the traditional diameter-based methods for endograft sizing.

Project description:BackgroundThe aim of this retrospective study was to evaluate the feasibility and efficacy of thoracic endovascular aortic repairs (TEVAR) combined with looping chimney technique (LCT) for repairing aortic arch lesions and reconstructing left common carotid artery.MethodsTotal of 14 patients (mean age 52.86±14.46 years; range, 27-79; 10 men, 4 women) were included in the study from December 2016 to December 2018. Aortic arch pathologies of all patients with insufficient proximal landing zone (PLZ) were repaired by TEVAR under local anesthesia, before TEVAR, the left common carotid artery (LCCA) was protected by the guiding sheath from the retrograde brachial access, after aortic stent graft deployed, chimney graft was implanted to restore LCCA by LCT if necessary. All patients underwent computed tomography angiograph (CTA) 2 weeks, 3 months, 6 months and 1 year after surgery.ResultsPathology results of 14 patients included: type B aortic dissection (n=8), penetrating aortic ulcers (n=1), retrograde type A aortic dissection (n=1), thoracic aortic aneurysm (TAA) (n=2), and thoracic aortic pseudoaneurysm (n=2). In all patients, aortic arch lesions were repaired by TEVAR; while LCCA were successfully reconstructed by the LCT. In one case, the innominate artery (IA) was simultaneously reconstructed through the same percutaneous right brachial artery (RBA) access. Coiling eliminated type Ia endoleak in 3 patients, and type II endoleak vanished by plugging left subclavian artery (LSA) in 2 patients. In four patients, the chimney stent (CG) of LCCA was partially compressed and then another bare stent was implanted to restore patency rate. The mean follow-up duration was 9.77±6.64 months (range, 0-24) and no combinations were observed in 13 patients; except in one patient who died of cerebral hemorrhage due to abnormal coagulation function.ConclusionsTEVAR combined with LCT has shown to be suitable surgical approach for aortic arch lesions. Either covered intentionally or inadvertently, the LCCA could be safely and effectively reconstructed via percutaneous RBA access. Short-term follow-up demonstrated satisfactory morbidity and mortality in high-risk patients; however, longer follow-up is required to assess the effectiveness and durability of this innovative endovascular procedure.

Project description:ObjectivesOur goal was to identify the inferior mesenteric artery diameter and number of patent lumbar arteries causing a significant type 2 endoleak to develop after infrarenal endovascular aneurysm repair.Material and methodsIncluded were patients who underwent infrarenal endovascular aneurysm repair between April 2002 and January 2017. Patients with an aneurysm involving the iliac arteries were excluded. Significant type 2 endoleak was defined as a type 2 endoleak observed after infrarenal endovascular aneurysm repair and accompanied by abdominal aneurysm growth of at least 5 mm during that time.ResultsA total of 277 patients were included. Mean follow-up was 38.9 (standard deviation 121.6) months. Immediately after infrarenal endovascular aneurysm repair, type 2 endoleaks occurred in 55 patients (20%), resolving spontaneously in 2 patients 6 months after infrarenal endovascular aneurysm repair. Thirty (10.8%) patients revealed a significant type 2 endoleak with aneurysm sack enlargement > 5 mm during follow-up, for which inferior mesenteric artery or lumbar artery coiling was performed. Mean time for coiling after primary infrarenal endovascular aneurysm repair was 25.4 (standard deviation 19.10) months. Twenty-three patients (8.3%) showed a non-significant type 2 endoleak during follow-up (no aneurysm sack enlargement). We found that the inferior mesenteric artery diameter and number of patent lumbar arteries were factors associated with a significant type 2 endoleak (odds ratio 1.755, P = 0.001; odds ratio 1.717, P < 0.001, respectively). Prior to endovascular aneurysm repair, the inferior mesenteric artery was patent in 212 (76.5%) patients; its median diameter measured 3 (0.5-3.8) mm. The median number of patent lumbar arteries was 3 (2-4). According to our receiver operating characteristic curve analysis, an inferior mesenteric artery diameter ≥3 mm (sensitivity 93.3%, specificity 65%) and ≥3 patent lumbar arteries (sensitivity 87.5%, specificity 43.6%) proved to be optimal cut-off values related to developing a significant type 2 endoleak. We therefore propose a composite score for the development of a significant type 2 endoleak [(inferior mesenteric artery diameter + patent lumbar arteries)/2].ConclusionsPatients in whom the diameter of the inferior mesenteric artery is ≥ 3 mm and with ≥ 3 patent lumbar arteries carry a higher risk of developing significant type 2 endoleak after infrarenal endovascular aneurysm repair.

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Persistent Type I Endoleak after Endovascular Treatment with Chimney Technique.

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Persistent Type I Endoleak after Endovascular Treatment with Chimney Technique.

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