Endovascular Treatment for Delayed Type Ib Endoleak

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Endovascular Treatment for Delayed Type Ib Endoleak with Hostile Arterial Anatomy after Endovascular Abdominal Aortic Aneurysm Repair

Introduction

Abdominal aortic aneurysm (AAA) is a serious vascular condition that can lead to life-threatening complications if left untreated. Endovascular abdominal aortic aneurysm repair (EVAR) has emerged as a popular treatment option due to its minimally invasive nature. However, like any medical procedure, EVAR is not without its challenges. One such challenge is the occurrence of endoleaks, which can potentially lead to aneurysm rupture. In this article, we will discuss a case of delayed type Ib endoleak with hostile arterial anatomy after EVAR and the endovascular treatment approach used.

Case Presentation

A 71-year-old male patient was referred for an incidentally detected delayed type Ib endoleak on computed tomographic angiography (CTA). Seventeen months prior, he had undergone EVAR with the Zenith (Cook Inc, Bloomington, IN, USA) stent-grafts for a right common iliac artery (CIA) aneurysm with a diameter of 4.4 cm. At the time of referral, his vital signs were stable, and he had no related symptoms.

Pre-treatment Imaging

  • CTA at 8 months after EVAR: There was no endoleak. The stent-graft in the left CIA was well-configured (Figure 1A).
  • CTA at the time of referral (17 months after EVAR): A newly developed type Ib endoleak was detected at the left iliac limb. The stent-graft in the left CIA was angulated (Figure 1B).

Treatment Attempts and Challenges

  • Initial Attempt via Left Femoral Artery Puncture: This failed due to severe calcific stenosis and tortuosity of the external iliac artery (EIA).
  • Left Axillary Artery Puncture: A guidewire was passed into the main body and left limb and was captured by snaring through the left femoral artery. However, attempts to insert a stent-graft into the distal end of the preexisting stent-graft were unsuccessful. Angiography revealed that the guidewire had passed through a tiny space between the stent and graft and then exited toward the iliac artery lumen (Figure 1C).

Treatment Strategy and Intervention

  • Stenting to Correct Tortuosity: Another Zenith stent-graft with a diameter of 12 mm was inserted into the EIA to reduce its tortuosity. This allowed the guidewire to be passed through the pre-existing stent-graft into the proximal aorta.
  • Stent-Graft Insertion for Endoleak Management: Finally, a 12-mm diameter stent-graft was additionally inserted to manage the type Ib endoleak.

Post-treatment Imaging

At the 7th day postoperatively, CTA showed no endoleak. The stent-graft in the left CIA was recovered (Figure 1D). The patient was uneventfully discharged.

Discussion

EVAR and Endoleaks

EVAR has become the first-line treatment for abdominal aortic aneurysm in many cases. However, it has a higher risk of reintervention compared to open surgery. Type Ib endoleak is mainly caused by inadequate anatomy, such as a large diameter CIA, heavy calcification, or severe aortoiliac tortuous axis. Type I endoleaks can lead to an increase in the diameter of the aneurysm sac and potentially result in aneurysm rupture. This highlights the importance of continuous follow-up after EVAR.

Management of Type Ib Endoleak with Hostile Anatomy

  • Double Approach and Stenting: In cases of severe aortoiliac tortuosity, approaches such as a double approach (both femoral and axillary) or stenting to correct tortuosity can be effective. Once the tortuosity is addressed, stent-graft insertion for endoleak management can be attempted.
  • Importance of Intermittent Angiography: In our case, although a double approach was attempted, the guidewire did not travel within the intended pathway as expected. Performing intermittent angiography during procedures can help prevent greater complications by ensuring the correct placement of instruments.

Follow-up and Reintervention Probability

Delayed type Ib endoleak is rare, but persistent follow-up after EVAR is necessary to remind patients of the probability of reinterventions.

Conclusion

In conclusion, endovascular treatment for delayed type Ib endoleak with hostile arterial anatomy after EVAR can be challenging. However, with the use of appropriate techniques such as double approaches, stenting to correct tortuosity, and intermittent angiography, successful management can be achieved. Continuous follow-up after EVAR is essential to detect and manage potential endoleaks and other complications.

References

  1. Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, et al. Editor’s choice – European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg 2019;57:8–93. doi: 10.1016/j.ejvs.2018.09.020.
  2. EVAR Trial Participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005;365:2179–2186. doi: 10.1016/S0140-6736(05)66627-5.
  3. Coulston J, Baigent A, Selvachandran H, Jones S, Torella F, Fisher R. The impact of endovascular aneurysm repair on aortoiliac tortuosity and its use as a predictor of iliac limb complications. J Vasc Surg 2014;60:585–589. doi: 10.1016/j.jvs.2014.03.279.
  4. Falkensammer J, Hakaim AG, Oldenburg WA, Neuhauser B, Paz-Fumagalli R, McKinney JM, et al. Natural history of the iliac arteries after endovascular abdominal aortic aneurysm repair and suitability of ectatic iliac arteries as a distal sealing zone. J Endovasc Ther 2007;14:619–624. doi: 10.1177/152660280701400503.
  5. Henrikson O, Roos H, Falkenberg M. Ethylene vinyl alcohol copolymer (Onyx) to seal type 1 endoleak. A new technique. Vascular 2011;19:77–81. doi: 10.1258/vasc.2010.oa0257.

doi.org/10.1097/CM9.0000000000001784

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