Treatment timing and options of type I endoleak after Endo-Vascular aortic Aneurysm Sealing (EVAS)

MethodsAn 81 year old male patient, with relevant comorbidities, was known for an EVAS procedure on an asymptomatic infra-renal aneurysm performed 19 months earlier. Subsequent right branch recurrent occlusion imposed revascularization through a cross-over bypass graft. A type IA endoleak caused a slow growth of the aneurysmal sac (from 55 to 57 mm in 12 months). He was therefore planned for open repair with removal of the graft. 30 days later he presents with acute abdominal pain, a rapid sac growth (13 mm) and graft migration at CT scan with signs of imminent rupture.

IntroductionThe Nellix Endo-Vascular Aneurysm Sealing (EVAS) system has been developed for the treatment of infra-renal aneurysms with favourable and adverse anatomy, potentially reducing the need for secondary interventions. A low incidence of type I endoleaks and consequent graft migration has been reported so far in literature. In spite of this, treatment in case of graft migration with or without aneurysm rupture constitutes a serious challenge which vascular surgeons will be increasingly faced with in the near future.Our objective is to propose a treatment option for this severe complication and to share our experiencewith it.

Prouse G., Rosso R., Engelberger S., Giovannacci L.,Department of Surgery, Regional Hospital of Lugano

ConclusionOpen repair and removal of the graft and of the aneurysm sealing system remains the only safe treatmentchoice in case of EVAS device migration.Type I endoleaks with this kind of graft have to be treated aggressively because evolution to completegraft migration and aneurysm rupture may be unexpectedly rapid.

References(1)Endovascular Aneurysm Sealing for Juxtarenal Aneurysm Using the Nellix Device and Chimney Covered Stents, Dijkstra M.L. et al. J Endovasc Ther. 2014 Aug; (2)EVAR using the Nellix Sac-anchoringendoprosthesis: treatment of favourable and adverse anatomy, Krievins DK et al. Eur J Vasc Endovasc Surg. 2011 Jul; (3) Management of a type Ia endoleak with the Nellix endovascular aneurysmsealing system.Hughes CO et al. J Endovasc Ther. 2015 Jun; (4) Multicenter Nellix EndoVascular Aneurysm Sealing system experience n aneurysm sac sealing, Böckler D et al. J Vasc Surg. 2015 Aug

ResultsEmergency open aneurysm repair with a bifurcated graft was performed. The removal of the EVAS device did not pose any technical problems, mainly due to the absence of a supra-renal anchoring system.