management of endoleaks.ppt - suny downstate … · management of endoleaks sarah ikponmwosa...

Management of gEndoleaks

Sarah Ikponmwosa MDSarah Ikponmwosa, MDBrooklyn VA

6/20/08

www.downstatesurgery.org

Questions

Advantages of endovascular repairDefinition of an endoleakTypes of endoleaksManagement of type lll endoleakManagement of type lll endoleakDiagnosis of type ll


Case Presentation

86 male s/p endovascular repair of left internal iliac artery aneurysm in 2004 -expanding left iliac aneurysm on follow up imaging.

Patient complained of left hip painp p p


Case Presentation

PMH – HTN, BPH

PSH – Endovascular repair of left internal aneurysm, LIHRinternal aneurysm, LIHR

Meds labetalol lisinopril nexiumMeds – labetalol, lisinopril, nexium, flomax


Evaluation

PE• NAD• Abd – soft, nt,nd• Extr – warm, 2+ pulses throughout

• Labs wnl• Creatinine 1.3


Case Presentation

Work-up – Abd. US showed a 4.9cm dilatation of th l ft i t l ili tthe left internal iliac artery

Th d i i d t t k th ti t t thThe decision was made to take the patient to the OR for formal angiogram to r/o an endoleak and for possible embolizationp


Case Presentation

Intra-operative finding - no endoleak

Patient was discharged after adequate observationobservation


Management of Endoleaks

Questions?


Introduction

An arterial aneurysm - permanent localized enlargement of > 1.5 times its expected diameterdiameter Common morphology is a fusiform, symmetrical circumferential enlargement thatsymmetrical, circumferential enlargement that involves all layers of the arterial wall. Most common cause - atheroscleroticMost common cause atherosclerotic degeneration of the arterial wall


Introduction

Most common - infrarenal aorta aneurysm

In the United States, AAAs result in approximately 15,000 deaths/yr

Death rate - reduced by identifying and treating aortic aneurysms before they rupture


IntroductionA l i k fAnnual risk of rupture • 1% to 2% for aneurysms < 5 cm• 10% for aneurysms 5 to 6 cm• 25% or higher for aneurysms > 6 cm25% or higher for aneurysms > 6 cm

Large aneurysms - much more likely to rupture but small d d taneurysms can and do rupture

Decision to treat - assessment of the risk rupture relative to the risk associated with treatment rather than on an absolute sizecriterion.


Pathogenesis

Multifactorial process • Genetic predisposition (e.g. Ehlers-Danlos

syndrome, Marfan syndrome)• Aging • Ath l i• Atherosclerosis• Inflammation (tertiary syphilis)• localized activation of proteolytic enzymes• localized activation of proteolytic enzymes


Diagnostic modalitiesUltrasound -• ready availability in both inpatient and outpatient settings• low cost• safety• good performance

Limitations • imaging of the thoracic and suprarenal aorta is poor • quality of the images is considerably lower - obesity or large

amounts of intestinal gasg• requires a skilled imaging technician


Diagnostic modalities

Aortography • excellent images of the contours of the aortic lumen• t li bl th d f d t i i th di t f• not a reliable method for determining the diameter of

an aneurysm or even for establishing its presence because the mural thrombus within the aneurysm t d t d th l t l itends to reduce the lumen to near-normal size.

• helpful in determining the extent of an aneurysm especially when there is iliac or suprarenal p y pinvolvement


Aortography


Diagnostic modalitiesCTCT scan• reliable information about the size of the entire aorta• allows accurate determination of both the size and the

extent of the aneurysmextent of the aneurysm• permits identification of the visceral and renal arteries and

their relationship to the aneurysm. • I.V. contrast material allows assessment of the aortic

lumen, the amount and location of mural thrombus, and the presence or absence of retroperitoneal hematoma

• currently the most useful imaging method for evaluation of the abdominal aortathe abdominal aorta

MRI• no nephrotoxic contrast agents are used.


Classification of Patients For RepairClassification of Patients For Repair

3 categories according to presentation:

• elective patients

• symptomatic patients

• patients with ruptured aneurysms.


Indications for elective repair

• Asymptomatic patients who have aneurysms 5.0 cm in diameter or larger

• An acceptable level of operative risk and life expectancy of 1 year or more.

• <5.0 cm who are not at high operative risk who live in a remote area where proper medical care is not readilyremote area where proper medical care is not readily available.

• 4.0 and 5.0 cm in diameter and have shown growth of more than 0.5 cm on serial images in less than 6 to 12 months.than 0.5 cm on serial images in less than 6 to 12 months.

• Peripheral embolization originating from the aneurysm, regardless of the size of the aneurysm.


Classification of Patients for Elective or Urgent Repairor Urgent Repair

Urgent operation • symptomatic aneurysms, regardless of the

size of the aneurysm.

E tiEmergency operation • all patients with known or suspected rupture

of an aneurysmof an aneurysm.


Operative method

Endovascular vs Open

Endovascular aneurysm repair (EVAR)• Introduce certain morphologic criteria into theIntroduce certain morphologic criteria into the

process of patient selection, • Stent grafting is appropriate only for patients g g y

in whom the infrarenal neck and the iliac arteries are suitable


Endovascular repair of Endovascular repair of Aneurysms

Endovascular repair was introduced during the 1990s - less invasive approach• Stent-graft is placed endoluminally via

bilateral groin incisions; • No need for a major abdominal incision and

aortic clampingaortic clamping. • Results to date have been promising


Endovascular repair of Endovascular repair of Aneurysms

Advantages • Blood loss is decreased

• Hospital stay is shortened

• Earlier return to function is achieved

Zarins CK, White RA, Schwarten D, et al: AneuRx stent graft vs. open surgical repair of abdominal aortic aneurysm: multicenter prospective clinical trial. J Vasc Surg 29:292, 1999 Makaroun MS: The Ancure endografting system: an update. J Vasc Surg 33:S129, 2001


PREOPERATIVE PREPARATION B h CTA d i h d f hiBoth CTA and angiography are used for this purpose. CTA is currently preferred

CTA accurately defines • proximal and distal characteristics of the aneurysm• detects any significant renal visceral or iliac occlusive• detects any significant renal, visceral, or iliac occlusive

disease. • helpful in defining the infrarenal neck between the

renal arteries and the proximal portion of therenal arteries and the proximal portion of the aneurysm.


PREOPERATIVE PREPARATION

Angiography - complement to spiral CTA • defines renal, mesenteric, and distal arterial

tanatomy; • characterize tortuosity, calcification, and stenoses

in access arteriesin access arteries• determine the angles between the aorta, the

proximal neck, and the aneurysm.


Intra-operative imaging

Intravascular ultrasonography (IVUS) • Intraoperative imaging adjunct in the process of

sizing and selecting endograft componentssizing and selecting endograft components. • Used to measure vessel diameters and landing

zone lengths• Determine the amount of mural thrombus in the• Determine the amount of mural thrombus in the

aneurysm neck. • Can also be used to identify the renal and

h t i t i ll i th d ft t bhypogastric arteries, allowing the endograft to be deployed with minimal or no resort to angiography.


Post–op monitoring

CT scan with IV contrast • Within 1 month after EVAR

• Then at 6 months if any problems detected

• Annually if no problems detected


Complications

Procedure-related mortality - 1% to 2% (5% open)EndoleaksEndograft migration over timeAneurysm enlargementOccasional aneurysm rupture y p


Complications

Lower Extremity Ischemia

• Technical error such as a poor anastomosis, graft kinking, or compression

• Requires immediate surgical correction.


ENDOLEAKENDOLEAK

Persistent blood flow outside the lumen of the endoluminal graft but within an aneurysm sac being treated by the devicebeing treated by the deviceFailure of the stent-graft to totally exclude blood flow to the aneurysm sac.Major cause of complications and failure in endoluminal treatment of aneurysms. C ti d i ti f thContinued pressurization of the aneurysm sac and may leave the patient at risk of an rupture.


Endoleak TypesFour types

Type I endoleak: Incomplete seal or ineffective seal at yp pthe end of the graft.

- early course of treatment, but may also occur later.

Type II endoleak: due to opposing blood flow from collateral vessels.

- Inflow and outflow develops creating active blood- Inflow and outflow develops creating active blood flow within channel created within the aneurysm sac.


Type I endoleak


Type II endoleak


Endoleak TypesT III d l k I d i ff iType III endoleak: Inadequate or ineffective sealing of overlapping graft joints or rupture of the graft fabric. • occur early after treatment• due to technical problems• later due to device breakdown

Type IV endoleak:• due to the porosity of the graft fabric causing blood todue to the porosity of the graft fabric, causing blood to

pass through from the graft and into the aneurysm sac.


Type III leak


Endoleak TypesType V endoleaks• Continued expansion of the aneurysm sac in the

absence of a visualised endoleak on conventional imaging.

• ‘Endotension’ - continued pressurisation of the aneurysm sac.y

• Important to exclude the presence of a subtle endoleak by further investigation such as contrast enhanced ultrasound

Gilling-Smith G, Brennan J, Harris P, et al. Endotension after endovascular aneurysm repair: definition, classification, and strategies for surveillance and intervention. J Endovasc Surg 1999;6:305– 7


Management of Type I leaksT 1Type 1Small type IA leaks observe,for,at,least 1 month then in at 6 months. If a leak is still present at 6 months, investigate with angiographically and provide treatment g g p y p

• Treatment of type IA endoleaks most often involves ballooning the site

• if a leak persists, additional stents or extension cuffs can be deployed over the attachment areas.

Bernhard VM, Mitchell RS, Matsumura JS, et al. Ruptured abdominal aortic aneurysm after endovascular repair. J Vasc Surg. 2002;35:1155-1162.

Van Marrewijk C, Buth J, Harris PL, et al. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: The EUROSTAR experience. J Vasc Surg. 2002;35:461-473.y p g ;


Management• Many early ruptures were linked to type IB endoleaks

seen with first-generation tube grafts. • Bifurcated or monoiliac grafts are now the standard of g

care. • Imperative to create an adequate distal seal between

the graft and iliac arteryg y• Majority require reintervention• Late endoleaks can occur at the distal attachment site

when the length of the seal is shortwhen the length of the seal is short. • Coils have been successfully though primarily used for

type II endoleaks


Diagnosis of Type II leaksTi i f i j i d i h CT ill d i h hTiming of contrast injection during the CT scan will determine whether a type II endoleak is visible.

Due to the nature of retrograde flow, these can be very low-flow systems.

Delayed films may be necessary to assess late perfusion within the sac and should be performed with any suspicion of type II endoleak.p y p yp

P DJ K l DO R b t I t l T II d l k P di t bl t bl d ti t t bl ?Parry DJ, Kessel DO, Robertson I, et al. Type II endoleaks: Predictable,preventable, and sometimes treatable? J Vasc Surg. 2002;36:105-110.

Mussack T, Biberthaler P, Trupka A, et al. Laparoscopic clipping of the inferior mesenteric artery for persistent endoleak after endovascular stent graft treatment of abdominal aortic aneurysm: A case report. Vasc Surg.2000;34:635-640


Management of Type II leaksM l l dl f fMost spontaneously resolve, regardless of graft type.

Some patients will demonstrate stability or even shrinkage of th i th f t t t II d l kthe aneurysm sac in the presence of a patent type II endoleak.

Current treatment of type II endoleaks - behavior of the aneurysm sac most of which can be safely observed for 6aneurysm sac, most of which can be safely observed for 6 months.

• if the sac expands during this time or at a later date, • ti t h ld d i h d• patient should undergo angiography and• treatment usually in the form of embolization of feeding and draining

vessels.


Management of Type III

• Disjunction between modular components (type IIIA) or• Hole in the fabric of the graft (type IIIB). • Type III endoleaks are very graft specific and can be• Type III endoleaks are very graft-specific and can be

serious because they are invariably associated with a sudden elevation of intrasac pressure.

• All should be repaired as soon as they are detected. • Successfully corrected with a modular extension or covered

stent

Makaroun M, Zajko A, Sugimoto, et al. Fate of endoleaks after endoluminal repair of abdominal aortic aneurysms with an EVT device. Eur J Vas Endovasc Surg. 1999;18:185-190.


Management of Type IV

Type IV endoleaks • caused by fabric porosity • subside within 30 days. • No specific treatment is necessary.


ConclusionType I and Type III endoleaks - secondary treatment to prevent possible aneurysm rupture. Significance of type II endoleaks is less certainSignificance of type II endoleaks is less certainNo clear evidence that type II endoleaks lead to aneurysm rupturey pEndoleaks should be treated if associated with aneurysm enlargement.


Questions

Advantages of endovascular repairDefinition of an endoleakTypes of endoleaksManagement of type lll endoleakManagement of type lll endoleakDiagnosis of type ll


management of endoleaks.ppt - suny downstate … · management of endoleaks sarah ikponmwosa...

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