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Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously.

ABSTRACT: OBJECTIVE:The Society for Vascular Surgery reporting standards for endovascular aneurysm repair (EVAR) consider the presence of a type I or type III endoleak a technical failure. However, the nature and implications of these endoleaks in fenestrated EVAR (FEVAR) are not well understood. METHODS:We performed a single-center retrospective review of 53 patients who underwent FEVAR with the Zenith Fenestrated AAA Endovascular Graft (Cook Medical, Bloomington, Ind) from 2013 to 2018. We excluded one patient without contrast-enhanced postoperative imaging who was lost to follow-up after discharge. Small, slow, type I and type III endoleaks on completion angiography were routinely observed. We identified patients with completion type I or type III endoleaks by angiography review and characterized endoleak type, location, and rate of resolution on initial postoperative imaging. RESULTS:Fifty-two patients were included; mean age was 75 ± 8 years, 75% were male, and 91% were white. Of 146 visceral vessels (100 renal arteries and 46 superior mesenteric arteries), 145 (99%) were preserved with 103 fenestrations and 43 scallops; 102 (70%) target vessels were stented. After implantation of all device components, 31 patients (60%) had evidence of type I or type III endoleak. Twelve patients (39%) underwent further intervention at the index procedure, and three endoleaks resolved completely. Twenty-eight patients (54%) had a type I or type III endoleak on completion angiography. There were no differences between patients with and without completion endoleaks in baseline demographics, graft design, neck anatomy, or proportion of cases performed within the instructions for use of the device. Perioperative mortality was 1.9%. On initial postoperative imaging, 27 of 28 (96%) endoleaks resolved spontaneously. One small, persistent type IA or type III endoleak was identified on postoperative day 27 and was observed. This endoleak had resolved completely on computed tomography angiography 6 months postoperatively. In patients without a completion endoleak, one type IA endoleak secondary to graft infolding was discovered on postoperative imaging and was successfully treated with placement of endoanchors and Palmaz stent. Median follow-up was 269 days. No additional type I or type III endoleaks were identified in any patient for the duration of follow-up. CONCLUSIONS:Whereas completion type I and type III endoleaks are common after FEVAR with the ZFEN device, nearly all of these endoleaks resolve spontaneously by the initial postoperative imaging. These results suggest that select completion endoleaks after FEVAR with the ZFEN device do not require intervention at the index procedure.

SUBMITTER: Swerdlow NJ

PROVIDER: S-EPMC6588517 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously.

Swerdlow Nicholas J NJ McCallum John C JC Liang Patric P Li Chun C O'Donnell Thomas F X TFX Varkevisser Rens R B RRB Schermerhorn Marc L ML

Journal of vascular surgery 20181221 2

<h4>Objective</h4>The Society for Vascular Surgery reporting standards for endovascular aneurysm repair (EVAR) consider the presence of a type I or type III endoleak a technical failure. However, the nature and implications of these endoleaks in fenestrated EVAR (FEVAR) are not well understood.<h4>Methods</h4>We performed a single-center retrospective review of 53 patients who underwent FEVAR with the Zenith Fenestrated AAA Endovascular Graft (Cook Medical, Bloomington, Ind) from 2013 to 2018. W ...[more]

PMID: 30583892

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Project description:ObjectiveFenestrated or branched endovascular aortic arch repair (fb-arch repair) is an effective option for treating complex aortic arch lesions, including thoracic aortic aneurysms and aortic dissections. However, the relatively high rate of re-intervention due to target vessel (TV)-related endoleaks have raised concerns. This study aimed to determine risk factors for TV-related endoleaks after fb-arch repair.MethodsThis was a retrospective analysis of all patients undergoing fb-arch repair between 2017 and 2021in nanjing drum tower hospital of China. All the patients underwent computed tomography angiography (CTA) before surgery; at discharge; and at 3 months, 6 months, and yearly post-discharge. All procedures are performed with physician modified grafts. Two experienced vascular surgeons used CTA and vascular angiography data to assess endoleaks. The study endpoints were mortality, aneurysm rupture, and emergence of and re-intervention for TV-related endoleaks.ResultsDuring the follow-up period, 218 patients underwent fb-arch repair. There were seven perioperative deaths and four deaths during follow-up (two myocardial infarctions and two malignancies). There were nine additional patients who were excluded from the study (two strokes, three with abnormal aortic arch anatomy, and four with insufficient clinical data). Among the 198 patients considered (mean age, 59 ± 13.3 years; 85% male), 309 branch arteries were revascularized. A total of 35 TV-related endoleaks were identified in 28 patients during a mean follow-up of 23 ± 14 months (median 23, IQR 26.3): six type Ic, 4 type IIIb, and 20 type IIIc endoleaks. Patients in the endoleak group had greater aortic arch segment diameters (43.1 ± 5.1 vs. 40.3 ± 4.7; P = 0.004) and a greater number of TVs revascularized (2.0 ± 0.8 vs. 1.5 ± 0.8; P = 0.004) than those in the non-endoleak group. However, the morphological classification of the aortic arch did not seem to affect the occurrence of TV endoleaks (13%, 14%, and 15% for type І, II, and III aortic arches, respectively; P = 0.957). Pre-sewing branch stents in the fenestration position reduced the risk of TV endoleaks (5% vs. 14%; P = 0.037). Additionally, in TVs affected by aortic aneurysm or dissection, the risk of endoleaks increased after reconstruction (17% vs. 8%; P = 0.018). The incidence of secondary TV-related endoleaks after fb-arch repair was 14.1%.ConclusionThe data from this study showed that the incidence of secondary target vessel related endoleaks after fb-arch repair is approximately 14.1%. Additionally, patients with a larger aortic arch diameter or more revascularized arteries during surgery were at increased risk TV-related endoleaks. The target vessels originating from the false lumen or aneurysm sac are more prone to endoleaks after reconstruction. Finally, prefabricated branch stents reduced risk of TV-related endoleaks.

Project description:Objective The aims of the present study were to explore the risk factors for type 2 endoleaks (T2ELs) after endovascular aneurysm repair (EVAR) and the association between T2ELs and the iliolumbar artery. Materials and methods A single-center, retrospective case–control study in West China Hospital was conducted among patients with infrarenal abdominal aortic aneurysm (AAA) who underwent EVAR between June 2010 and June 2019. The associations of patient characteristics, anatomical factors, internal iliac artery embolization, and ILA with the primary outcome were analyzed. The secondary objective was to analyze survival and reintervention between the T2EL group and the non-T2EL group. Kaplan–Meier survival, propensity matching analysis and multivariate logistic regression analysis were used. Results A total of 603 patients were included. The median follow-up was 51 months (range 5.0–106.0). There was a significant difference in the diameter of the lumbar artery (LA), middle sacral artery (MSA) and inferior mesentery artery (IMA), proportion of thrombus and LA numbers. The univariate analysis showed that T2ELs were more likely to develop more thrombus in aneurysm cavity (OR = 0.294, p = 0.012), larger MSA (OR = 1.284, p = 0.04), LA (OR = 1.520, p = 0.015), IMA (OR = 1.056, p < 0.001) and more LAs (OR = 1.390, p = 0.019). The multivariate analysis showed that the number of LAs (HR: 1.349, 95% CI: 1.140–1.595, p < .001) and the diameter of the IMA (HR: 1.328, 95% CI: 1.078–1.636, p = 0.008) were significantly associated with T2ELs. There were no new findings from the propensity score matching. The reintervention-free survival rates were significantly different between the two groups (p = 0.048). Overall survival and AAA-related death rates were not different between the two group. This was consistent with the PSM analysis. Conclusion The iliolumbar artery and the different internal iliac artery interventions may not increase the incidence of T2ELs. But the numbers of LAs and IMA diameter were independent risk factors for T2Els. T2ELs was associated with the reintervention but did not affect long-term survival or increase aneurysm-related mortality after EVAR.

Project description:IntroductionAlarming outcomes have been reported following infected endovascular aortic aneurysm repair (EVAR) device explantation. Infected fenestrated EVAR (FEVAR) exposes patients to even worse procedural risks.ReportA 67 year old man with a prior history of FEVAR presented with impaired general condition, abdominal and back pain, and increased C reactive protein. Computed tomography angiography revealed a collection around the aortic graft bifurcation and 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed increased FDG uptake at this level, confirmed by labelled white blood cells, all favouring graft infection. A thoracophrenolumbotomy was performed and revealed an aorto-enteric fistula which was treated by small bowel resection. The left renal artery was transected at the distal end of the bridging stent and a thoracorenal bypass was performed. The thoracic aorta was cross clamped above the coeliac trunk for complete graft excision. Meanwhile, the right kidney was perfused with 4°C Ringer lactate solution. In situ reconstruction was accomplished with a bifurcated antimicrobial graft sutured below the superior mesenteric artery with re-implantation of the right renal artery. The patient was left with a laparostomy for definitive abdominal closure, restoration of the digestive tract, and omental wrap 72 hours later. Broad spectrum antibiotic therapy was initiated peri-operatively and reduced to sulfamethoxazole/trimethoprim for a total duration of six weeks after one sample was positive for Moraxella osloensis. Eleven months later, the patient was free from re-infection, with no fever or inflammatory syndrome.DiscussionTotal explantation of stent grafts with tissue debridement and post-operative antibiotic therapy is the gold standard when dealing with infected EVAR. As with type IV thoraco-abdominal aneurysm open repair, FEVAR device explantation requires additional protective measures to prevent visceral ischaemia and renal impairment. In agreement with the European Society for Vascular Surgery guidelines, such patients should be referred to dedicated vascular centres with expertise in surgical repair, anaesthetics, and post-operative intensive care.

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Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously.

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Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously.

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