Intervention after endovascular aneurysm repair: Endosalvage techniques including perigraft arterial sac embolization and endograft relining.
Endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysm (AAA). However, persistent AAA sac endoleak following EVAR can result in sac diameter increase requiring re-intervention in up to one-third of cases and even result in aneurysm rupture. In this case review, we summarize and detail endovascular re-interventions for each type of endoleak. We also detail specific options including stent-graft relining for indeterminate, Type III, and Type IV endoleaks and perigraft arterial sac embolization to induce thrombosis and resolve acute Type I, II, or III endoleaks. Endograft relining involves placement of a new stent-graft-elevating the bifurcation and extending the repair from renal artery to hypogastric arteries; perigraft arterial sac embolization involves placement of a catheter into the excluded sac from common femoral artery access, characterization of the inflow and outflow of the endoleak, and inducing cessation of the blood flow into the sac by the administration of thrombogenic material. Endoleaks range from low-pressure endoleaks, which can be safely monitored in a surveillance program to high-pressure endoleaks, which mandate intervention when associated with AAA sac diameter increase to protect from rupture. The evaluation of new devices and techniques to treat endoleak after EVAR remains an important issue in patient care after EVAR.
Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, 9434 Medical Center Drive, Mail Code 7403, La Jolla, CA 92037; Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA. Electronic address: abarleben@ucsd.edu.
Andrew
A
Barleben
Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, 9434 Medical Center Drive, Mail Code 7403, La Jolla, CA 92037; Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA.
Tazo
T
Inui
Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA.
Erik
E
Owens
Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, 9434 Medical Center Drive, Mail Code 7403, La Jolla, CA 92037; Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA.
John S
JS
Lane
Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, 9434 Medical Center Drive, Mail Code 7403, La Jolla, CA 92037; Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA.
Dennis F
DF
Bandyk
D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D004621:Embolization, Therapeutic / Q000379:methods*; D057867:Endoleak / Q000145:classification / Q000209:etiology / Q000601:surgery*; D057510:Endovascular Procedures / Q000009:adverse effects; D006801:Humans; D012086:Reoperation; D016896:Treatment Outcome