title: Treatment of type I endoleak after endovascular repair of infrarenal abdominal aortic aneurysm: success of fibrin glue sac embolization.
abstract: OBJECTIVE
  To analyze a single-center experience of fibrin glue sac embolization to eliminate type I endoleaks after endovascular aneurysm repair (EVAR), assessing the feasibility and effectiveness of the technique in long-term follow-up.
  
  
  METHODS
  A retrospective study was conducted involving 783 EVAR patients treated between August 2002 and February 2009. Under a standardized protocol, 42 (5.4%) patients (37 men; mean age 73 ± 8 years) underwent intraoperative transcatheter fibrin glue sac embolization to resolve type I endoleak persisting after initial intraoperative maneuvers to close the leak or in necks too short or angulated for cuff placement. Intrasac pressure was measured before and after glue injection. Computed tomographic angiography was performed to assess the outcome after 3, 6, and 12 months and annually thereafter.
  
  
  RESULTS
  In this type I endoleak cohort, 16 (38.1%) patients had proximal necks <10 mm long, and 5 (11.9%) patients had proximal neck angulation >60°; 22 additional devices (8 stents, 14 cuffs) had been placed in the initial attempts to resolve the endoleaks. After fibrin glue injection, 41 (97.6%) of the 42 endoleaks were resolved using a mean 15 ± 10 mL of glue. Intrasac pressure decreased significantly in successfully treated cases. The patient who failed embolotherapy was converted to open surgery (2.4%); he died 2 months later from multiorgan failure. Two (4.8%) patients died in the perioperative period from myocardial infarction. One (2.4%) patient developed right lower extremity ischemia unrelated to the fibrin glue treatment. There were no allergic reactions. Over a median follow-up of 39.9 months (range 10-88), 3 (7.1%) patients died (1 aneurysm-related). Cumulative survival was 90.5% at 1 year, 87.0% at 3 years, and 82.6% at 5 years. The mean maximal aneurysm diameter fell from the baseline 59.5 ± 14.7 mm to 49.0 ± 11.6 mm (p<0.001). Of the 4 patients with increased aneurysm diameter during follow-up, 1 was converted, 2 are being observed due to advanced age, and 1 died of renal failure. No recurrent type I endoleak or glue-related complications were observed in follow-up.
  
  
  CONCLUSIONS
  Fibrin glue sac embolization to eliminate type I endoleak after EVAR yielded excellent results in our experience, effectively and durably resolving the leaks. Balloon occlusion of the proximal aorta must be done during glue injection to block proximal flow and facilitate formation of a structured fibrin clot.
authors.affiliation: Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China.
authors.forename: Qingsheng
authors.initials: Q
authors.lastname: Lu
authors.forename: Jiaxuan
authors.initials: J
authors.lastname: Feng
authors.forename: Yang
authors.initials: Y
authors.lastname: Yang
authors.forename: Bing
authors.initials: B
authors.lastname: Nie
authors.forename: Junmin
authors.initials: J
authors.lastname: Bao
authors.forename: Zhiqing
authors.initials: Z
authors.lastname: Zhao
authors.forename: Xiang
authors.initials: X
authors.lastname: Feng
authors.forename: Yifei
authors.initials: Y
authors.lastname: Pei
authors.forename: Liangxi
authors.initials: L
authors.lastname: Yuan
authors.forename: Zhijun
authors.initials: Z
authors.lastname: Mei
authors.forename: Rui
authors.initials: R
authors.lastname: Feng
authors.forename: Zaiping
authors.initials: Z
authors.lastname: Jing
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D021721:Balloon Occlusion; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002681:China; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000401:mortality; D057867:Endoleak / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D015718:Fibrin Tissue Adhesive / Q000008:administration & dosage*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D015996:Survival Rate; D013997:Time Factors; D014014:Tissue Adhesives / Q000008:administration & dosage*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D015718:Fibrin Tissue Adhesive; D014014:Tissue Adhesives