A COMPLEX ENDOLEAK REPAIR Resident(s): Ihab Akladious, MD

Attending(s): Raj Pyne, MD

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

Originally Posted: December 01, 2014

CHIEF COMPLAINT & HPI

History of Present Illness

71 y/o female with history of thoracic and abdominal aortic aneurysms s/p combined TEVAR and EVAR with debranching procedure to reconstitute flow to the mesenteric arteries and kidneys (common graft from aortic bifurcation to right renal artery, proper hepatic artery, & SMA, and second graft from right common iliac artery to left renal artery), presents 5 months post-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 SURGERY

A: Coronal image from CT angiogram shows a Type II endoleak (arrow) within the native aneurysm sac adjacent to both thoracic and abdominal endografts

B and C: Sagittal and axial images from CT angiogram show a Type II endoleak with retrograde filling from the celiac trunk (arrows)

A B

C

DIAGNOSTIC WORKUP – CTA 5 MONTHS AFTER SURGERY

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 level of the diaphragmatic hiatus to the takeoff of the celiac axis, a result of retrograde filling from the debranching 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 graft? (click on one of the following answers)

A. Type I B. Type II C. Type III D. Type IV E. Type V

CORRECT!

Which type of endoleak is related to an inadequate seal at the ends of a stent graft? (click on one of the following answers)

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 vessel. 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 increase

(endotension).

CONTINUE WITH CASE

SORRY, THAT’S INCORRECT.

Which type of endoleak is related to an inadequate seal at the ends of a stent graft? (click on one of the following answers)

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 vessel. 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 increase

(endotension).

CONTINUE WITH CASE

INTERVENTION

After interdisciplinary discussion with 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 proposed pathway was drawn as a guide prior to the procedure.

Endoleak

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

Initial flush aortic angiogram with same proposed pathway outlined.

Graft from aortic bifurcation to right kidney, proper hepatic artery (highlighted pink), and SMA

Graft from right common iliac artery to left kidney

Liver

Rt kidney Lt kidney

GDA

Endoleak

INTERVENTION – PRE-EMBOLIZATION ANGIOGRAPHY

Magnified view demonstrating the vascular anatomy. Superselective angiography with a microcatheter placed in the celiac trunk clearly shows the Type II endoleak (arrows).

INTERVENTION – POST-EMBOLIZATION ANGIOGRAPHY

Post-embolization angiography demonstrates complete embolization of the large aneurysm sac and the celiac trunk after placement of multiple detachable framing coils and long detachable coils (arrows) as well as n-BCA glue liquid embolic. There were multiple unsuccessful attempts to find the feeding lumbar arteries, which were never visualized. Repeat angiography after 5 minutes confirmed no endoleak filling.

SUMMARY & TEACHING POINTS

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

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

• Proper planning was essential given the complicated anatomy following the debranching, and a map drawn based off of the CTA was invaluable in navigating to the origin of the endoleak at the celiac trunk

• Technically successful endovascular endoleak repair through the debranching graft via a retrograde approach from the proper hepatic artery with successful coil and glue embolization 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 the aortic wall C. Trans-arterial/trans-lumbar embolization of the endoleak cavity and feeding vessels D. Open surgical repair

CORRECT!

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 the aortic wall C. Trans-arterial/trans-lumbar embolization of the endoleak cavity and feeding vessels D. Open surgical repair

CONTINUE WITH CASE

SORRY, THAT’S INCORRECT.

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 the aortic wall C. Trans-arterial/trans-lumbar embolization of the endoleak cavity and feeding vessels D. Open surgical repair

CONTINUE WITH CASE

REFERENCES

Rosen R.J., Green R.M. Endoleak Management following Endovascular Aneurysm Repair. J Vasc Interv Radiol. 2008; 19(6):S37-S43

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

Bashir M.R., Ferral H. et-al. Endoleaks after endovascular abdominal aortic aneurysm repair: management strategies 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 endovascular repair of abdominal aortic aneurysm. AJR Am J Roentgenol. 2008;191 (3): 808-13