title: Treatment of sac expansion after endovascular aneurysm repair with obliterating endoaneurysmorrhaphy and stent graft preservation.
abstract: BACKGROUND
  Persistent type II endoleaks (T2Ls) with sac enlargement after endovascular abdominal aortic aneurysm repair are still of concern in view of the potential for rupture. Current treatments (embolization and stent graft [SG] explantation) are associated with lack of efficacy or high perioperative morbidity and mortality. This study evaluated an alternative technique that combines sacotomy, ligation of patent back-bleeding vessels, and SG preservation for T2L or unspecified endoleak repair.
  
  
  METHODS
  This multicenter study in France included 28 patients (27 men; median age, 78 years). Twenty-one patients (75%) had a bifurcated SG (including 3 fenestrated SGs) and seven (25%) had an aortouni-iliac SG (2 for ruptured aneurysm). Unsuccessful embolization had been performed in 10 patients (36%). Four patients (14%) presented sac enlargement with no endoleak visible on computed tomography. The origin of the endoleak remained unspecified in three patients 3 (11%). The median diameter of the aneurysmal sac was 78 mm (vs 55 mm at the time of endovascular abdominal aortic aneurysm repair) after a median follow-up of 24 months.
  
  
  RESULTS
  A transperitoneal approach was used in 21 patients (75%) and a retroperitoneal approach was used in seven (25%). A guidewire was placed in the supraceliac aorta in 14 patients, and an occlusion balloon was temporarily inflated in six. Aortic cross-clamping was performed in five patients. T2Ls were identified in 26 patients, and associated with a distal type I endoleak in 1 patient, a type III endoleak in 3, and a type IV endoleak in 1. Two patients presented with endotension. All the endoleaks were treated successfully, with a mean operating time of 120 minutes and a mean blood loss of 450 mL. One SG was explanted 12 days after the procedure because of early infection. One patient died during SG explantation for an aortoduodenal fistula 26 months after the endoaneurysmorrhaphy. During a median follow-up of 24 months, the control computed tomography scan showed shrinkage of the aneurysmal sac with stable diameters in all patients. No missed T2Ls, no recurrence of T2L, and no SG migration or disjunction was observed.
  
  
  CONCLUSIONS
  Obliterating endoaneurysmorrhaphy with SG preservation can be considered as an alternative to SG removal in cases of persistent T2L responsible for aneurysmal sac enlargement after embolization failure. By avoiding extensive dissection for surgical aortic cross-clamping, minimizing hemodynamic changes, and reducing blood loss and operating time, this procedure can be performed even in patients initially considered unfit for surgery.
authors.affiliation: Department of Vascular Surgery, Amiens University Hospital, Amiens, France. Electronic address: maitrias.pierre@chu-amiens.fr.
authors.forename: Pierre
authors.initials: P
authors.lastname: Maitrias
authors.affiliation: Department of Vascular Surgery, Rennes University Hospital, Rennes, France.
authors.forename: Adrien
authors.initials: A
authors.lastname: Kaladji
authors.affiliation: Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
authors.forename: Didier
authors.initials: D
authors.lastname: Plissonnier
authors.affiliation: Department of Vascular Surgery, Valenciennes Hospital, Valenciennes, France.
authors.forename: Sébastien
authors.initials: S
authors.lastname: Amiot
authors.affiliation: Department of Vascular Surgery, Clinique de l'Europe, Rouen, France.
authors.forename: Jean
authors.initials: J
authors.lastname: Sabatier
authors.affiliation: Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France.
authors.forename: Marc
authors.initials: M
authors.lastname: Coggia
authors.affiliation: Department of Vascular Surgery, Grenoble University Hospital, Grenoble, France.
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Magne
authors.affiliation: Department of Vascular Surgery, Amiens University Hospital, Amiens, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Reix
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D021721:Balloon Occlusion; D016063:Blood Loss, Surgical; D001807:Blood Vessel Prosthesis / Q000009:adverse effects; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D020878:Device Removal; D004621:Embolization, Therapeutic; D057867:Endoleak / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D005260:Female; D005602:France; D006801:Humans; D008026:Ligation; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D018579:Patient Selection; D011474:Prosthesis Design; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents / Q000009:adverse effects; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome