Endovascular device implantation for a type III endoleak following fabric tear

Dr. Patricio Zaefferer, Dr. Mariano Castelli, Dr, Guillermo Pfund, Dr. Ignacio de Luca.
Department of Vascular and Endovascular Surgery. Instituo Cardiovascular de Buenos Aires. Buenos Aires, Argentina

EVAR has been the most common treatment modality for AAA , in the  last  decade.1,2 Since then, many reports of EVAR related complications were described, including  stent grafts devices failure,  AAA  ruptures or both. Endovascular therapy for this new pathology is always challenging. In the worst scenario an open surgery has to be done.3 We present a case of a novel endovascular solution for the treatment of an enlarging abdominal aortic aneurysm, due to ruptured of a previous placed stent graft.

Relato de Caso:
We present an 80-year-old male with history of hypertension, dyslipidemia, non-insulin requiring diabetes and tobacco abuse, and a recent PTCA secondary to an abnormal stress test and an infrarrenal EVAR who, at 30 months CTA follow-up, was diagnosed with a type III B endoleak that led to device components disengagement.

The patient had been originally treated for a 94 mm (centerline measurement) asymptomatic infrarrenal AAA with a 38 mm right iliac aneurysm.  Under general anesthesia a 28-100/16-40 AFX main body with a 34-34/80-20 proximal suprarenal cuff and a 16-16/55 right iliac extension (Endologix, Irvine, CA) were deployed. After completion angiogram, a type IA endoleak was diagnosed at the proximal neck  and addressed with a 48 mm  Andrastent XXL balloon expandable stent (Andramed Medical Devices, Reutlingen, Germany). The patient recovered uneventfully and was discharged home on postoperative day 3. He afterwards fully complied his regular month 1, month 6 and month 18 follow-up with CT angiographies where neither endoleaks nor other complications were detected.

In the 30 month follow-up the patient concurred asymptomatic with a CT angiography that showed a 93 mm non-excluded aortic aneurysm with a type III B endoleak caused by complete disruption of the main body and the proximal cuff fabric, so repair was scheduled.

The case was planned using Endosize (Therenva SAS, Rennes, FR) software for 3D CT reconstruction and flow centerline analysis. Under general anesthesia in a hybrid O.R., through bilateral femoral cut down and left radial access, a 23 mm Ovation Prime device (TriVascular, Santa Rosa, CA) was placed with 12 mm iliac limbs inside the previous graft. After completion angiogram, a proximal endoleak was seen and treated by means of unsuccessful balloon angioplasty first, and successful bailout 48 mm balloon expandable stent placement Andrastent XXL (Andramed Medical Devices, Reutlingen, Germany). The patient required red cell transfusion and was discharged home at postoperative day 2. Postoperative CT (30 day) scan showed complete aneurysm exclusion and graft patency.

Several issues had to be taken into account when planning this case. In the first place, the previous graft fabric was completely disrupted, both the main body and the suprarrenal cuff. If the endoleak would have followed a component detachment (type III A), just placing an extra cuff would have probably solve the problem in a pretty less invasive manner. As the whole fabric was torn, the placement of a new endograft inside the prior one was mandatory.4,5 After this first step, we had to decide which graft would be the most suitable for this case. As we mentioned previously, the patient already had a balloon expandable stent placed at the proximal neck, so fixation of the new graft would have to be achieved over this stent. Therefore, barb fixation exclusively would be hindered, as no direct apposition between the graft and the aortic wall would be produce; so we considered that an alternative fixation method would better exclude the aneurysm. In this setting, we found Ovation Prime´s device polymer filled O-rings fixation system an adequate option to achieve an optimal proximal seal.

The other key issue that we had to bear in mind for appropriate graft selection was the fact that the patient had heavily calcified, tortuous and narrow lumen (4,5 mm bilateral) iliac arteries. Iliac anatomy precluded access with 18 Fr or larger sheaths, which is the size of most of the commercially available devices. The options to address this challenge were to try a low profile device or make a conduit for iliac access. An open approach to make a conduit was considered too risky in a patient who was still on clopidogrel because of a recent PTCA; and the option of an endoconduit was discarded because it would have been necessary to stage the procedure and delay the repair for at least 3 weeks, a non-viable option in a patient with a 93 mm non-excluded aneurysm.6,7

With all these considerations taken into account we believed that the best option to treat this patient, with the aforementioned situation, was the placement of a low profile, with active suprarenal fixation and proximal sealing ring with polymer, Ovation Prime device (Endologix, Irvine, CA.)

Fig 1 — Preoperative CT angiography with volumetric 3D reconstruction showing a 94 mm infrarrenal AAA.

Fig 2 — 1 month postoperative Ct scan control.

Fig 3 — 30 month-postoperative CT angiography showing type III endoleak due to complete disruption of the endograft´s main body fabric.

Fig. 4 — Preoperative procedure planning with device-specific image processing software. Note the heavily calcified iliac arteries

Fig 5 — Ovation Prime deployment.

Fig 6 — Completion Angiogram with complete aneurysm exclusion.

Fig.7 — Postoperative CT scan showing aneurysm exclusion with Ovation Prime device A) Multiplanar reconstruction. B) 3D volumetric rendering.
1. Karthikesalingam A, Holt PJ, Vidal-Diez A, Bahia SS, Patterson BO, Hinchliffe RJ, Thompson MM. The impact of endovascular aneurysm repair on mortality for elective abdominal aortic aneurysm repair in England and the United States. J Vasc Surg. 2016 Aug;64(2):321-327.e2.
2. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008 Jan 31;358(5):464-74.
3. Moulakakis KG, Dalainas I, Mylonas S, Giannakopoulos TG, Avgerinos ED, Liapis CD. Conversion to open repair after endografting for abdominal aortic aneurysm: a review of causes, incidence, results, and surgical techniques of reconstruction. J Endovasc Ther. 2010 Dec;17(6):694-702.
4. Chang RW, Goodney P, Tucker LY, Okuhn S, Hua H, Rhoades A, Sivamurthy N, Hill B. Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry. J Vasc Surg. 2013 Aug;58(2):324-32.
5. Candell L, Tucker LY, Goodney P, Walker J, Okuhn S, Hill B, Chang R. Early and delayed rupture after endovascular abdominal aortic aneurysm repair in a 10-year multicenter registry. J Vasc Surg. 2014 Nov;60(5):1146-52.
6. Peterson BG, Matsumura JS. Internal endoconduit: an innovative technique to address unfavorable iliac artery anatomy encountered during thoracic endovascular aortic repair. J Vasc Surg. 2008 Feb;47(2):441-5.
7. Jaldin, Rodrigo Gibin et al . Unfavorable iliac artery anatomy causing access limitations during endovascular abdominal aortic aneurysm repair: application of the endoconduit technique. J. vasc. bras., Porto Alegre , v. 13, n. 4, p. 318-324, Dec. 2014 .