Endovascular Treatment of Late “Endoleak” Following Open Surgical Repair Using Bypass and Exclusion Aneurysm Repair
Article Outline
Background
We sought to present endovascular management options of persistent or recurrent aneurysm sac flow (“endoleak”) after operative retroperitoneal exclusion of infrarenal abdominal aortic aneurysm (AAA).
Methods
Recurrent or persistent aneurysm perfusion was diagnosed in three patients primarily treated with aneurysm exclusion and bypass. The medical history, course of disease, and surgical management of these patients were reviewed.
Results
Three patients primarily treated for infrarenal AAA by division of the aorta with suture closure of the proximal aneurysm end, ligation of the outflow vessels, and bypass of the excluded aortoiliac segment presented with persistent or recurrent AAA sac perfusion and growth. The feeding vessels were the iliac arteries in all cases. Endovascular repair using coil embolization and/or deployment of an occluder or stent-graft was successful in all patients with a follow-up of 42, 36, and 30, months respectively.
Conclusion
Open AAA repair using the exclusion and bypass technique is associated with the risk of persistent perfusion or reperfusion of the aneurysm sac, which is similar to an endoleak after endovascular aortic aneurysm exclusion. Endovascular therapy should be considered as first-choice treatment when feasible.
Introduction
Until recently, the gold standard for treatment of abdominal aortic aneurysm (AAA) was repair with interposition of a straight or a bifurcated graft in inlay technique.1, 2 Several alternatives have been suggested, with endovascular surgery being the one with the highest potential to replace the standard open repair.3 Alternatively, division of the aorta, with double-suture closure of the proximal aorta and end-to-end proximal anastomosis, has been proposed (exclusion of the aneurysm).4, 5 When a bifurcated graft was used, the graft limb was sewn to the appropriate iliac or femoral artery in an end-to-end or end-to-side manner. Risks associated with this operation are the persistence of aneurysm sac perfusion or its reperfusion after inadequate ligation or loosening of the iliac artery ligations.
We report the cases of three patients primarily treated with aneurysm exclusion and bypass who were referred to our institution late after their original operation with persistent or recurrent aneurysm perfusion and expansion. In all cases, definite AAA exclusion was achieved using endovascular techniques.
Patients and methods
In three patients primarily treated with aneurysm exclusion and bypass, recurrent or persistent aneurysm perfusion was diagnosed. The medical history, course of disease, and management of these patients were reviewed.
Results
The patients' characteristics are shown in Table I.
Table I. Characteristics of three patients with “endoleak” after open repair of abdominal aortic aneurysm using the exclusion and bypass technique
| Distal anastomoses | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Age (y)/gender | Comorbidities | Symptoms | Interval since primary operation (y) | Proximal bypass anastomosis | right-sided | Left-sided | Endoleak feeding artery | Therapy | |
| Patient 1 | 64/male | Peripheral arterial disease, arterial hypertension | Pulsatile abdominal mass | 8 | End-to-end | End-to-end femoral | End-to-side EIA | Left EIA | Occluder in the left EIA and stent-graft |
| Patient 2 | 69/female | Coronary artery disease, peripheral arterial disease, arterial hypertension | Pulsatile abdominal mass | 9 | End-to-end | End-to-end femoral | End-to-side femoral | Left EIA | Coiling of the right EIA and left IIA |
| Patient 3 | 70/male | Congestive heart failure, three-vessel coronary artery disease, atrial fibrillation, peripheral arterial disease, arterial hypertension, diabetes mellitus | None | 13 | End-to-end | End-to-side EIA | End-to-end EIA | Right EIA | Coiling of the left CIA and occluder in the right CIA |
Case 1
The patient had undergone open retroperitoneal AAA exclusion 8 years earlier with aorto–right femoral, left external iliac bypass. According to the operation protocol, the left common iliac artery had been ligated during the primary operation. The computed tomography (CT) scan of the abdomen showed retrograde perfusion of the AAA with a maximal aneurysm diameter of 80 mm. The aneurysm sac had grown by more than 20 mm in comparison to the preoperative CT scan. Selective angiography was performed to verify the CT findings and to securely localize the origin of the retrograde perfusion. The left common iliac artery was identified as the source of reperfusion (Fig. 1A).
Fig. 1
(A)Selective digital subtraction angiography identified the left external lilac artery as the source of reperfusion (“endoleak”) of the aneurysm sac (arrows) after AAA exclusion and bypass. (B)Aneurysm (white arrows) exclusion by deployment of a Zenith occluder device (long yellow arrow) at the distal left common iliac artery and of a Hemobahn stent-graft (short yellow arrow), extending from the left limb of the original bifurcated bypass graft to the external iliac artery.
The possibilities of undergoing open or endovascular repair were discussed with the patient, who favored a minimally invasive treatment.
After obtaining percutaneous access over the left common femoral artery, an occluder device (iliac plug ZIP-16®; Zenith, William Cook Europe, Bjaerverskov, Denmark) was deployed in the distal common iliac artery. In addition, a stent-graft (Hemobahn®, 13×100mm; W. L. Gore & Associates, Flagstaff, AZ) was implanted extending from the left limb of the original bypass graft to the external iliac artery, converting in this way the end-to-side into an end-to-end left distal anastomosis to definitely prevent retrograde perfusion of the common iliac artery and the aneurysm sac (Fig. 1B). The postoperative course was uneventful.
After 42 months of follow-up, the patient remains free of symptoms and the CT scan of the abdomen showed complete thrombosis of the aneurysm sac with regression of the AAA maximal diameter from 80 mm to 74 mm.
Case 2
The time interval to primary AAA exclusion was 9 years. According to the protocol of the initial operation, the left external iliac artery had been ligated.
The CT scans of the abdomen and pelvis revealed a perfusion of the aneurysm sac presumably from the left iliac artery. A selective angiography was performed, which identified the left common iliac artery as the feeding vessel, perfused in a retrograde manner from the common femoral artery (Fig. 2). There was a communication to the right internal iliac artery bed via the “endoleak” (persistent or recurrent aneurysm sac flow) and lumbar arteries. The aneurysm sac had grown from 51 mm to 77 mm.
Fig. 2
Intraoperative selective catheterization of the left common and the right internal iliac artery, which communicate with each other (yellow arrows). The left common iliac artery was identified as the main feeding vessel of the “endoleak” within the aneurysm sac.
The patient was in good condition for open repair but favored the endovascular exclusion of the aneurysm. A percutaneous vascular access over the native left common femoral artery was gained, and a selective catheterization of the native right internal iliac artery was performed in cross-over technique. The right internal iliac artery as well as the “endoleak” and the narrow left common iliac artery were embolized with the use of Tornado® coils (William Cook Europe). The postintervention course of the patient was uneventful, and a control CT scan before discharge showed no perfusion of the aneurysm sac. At 36 months, the CT scan showed no significant regression of the maximal diameter of the severely calcified aneurysm and no contrast enhancement within the aneurysm sac. The patient was free of symptoms and no pulsatile abdominal mass was present.
Case 3
In the third patient, a proximal end-to-end, distal left-sided end-to-end and right-sided end-to-side anastomosis to the external iliac arteries had been performed. The CT scan of the abdomen demonstrated growth of the maximal diameter of the aneurysm sac compared to the preoperative CT scans and reperfusion of the aneurysm from the patent right external iliac artery (Fig. 3). Because of significant comorbidities of the patient, endovascular therapy was planned.
Fig. 3
Computed tomography angiography showing persistent arterial flow within the aortic sac 13 years after AAA exclusion and aorto-bi-iliac bypass with proximal end-to-end, distal left-sided end-to-end, and right-sided end-to-side anastomosis to the external iliac arteries. The right external iliac artery was the feeding vessel for the “endoleak” in this case.
Using a percutaneous access from the right femoral artery, the left native common iliac artery was catheterized in cross-over technique and coil-embolized to prevent a possible endoleak from the contralateral side. The right common iliac artery was then definitely occluded with a Zenith ZIP-14® iliac plug (William Cook Europe). The postoperative CT scan of the abdomen showed no retrograde perfusion of the aneurysm. The further postoperative course was uneventful. At 30 months of follow-up, the maximal AAA sac diameter regressed from 73 mm to 70 mm without “endoleak.”
Discussion
The standard surgical treatment of AAA is the exclusion of the aneurysm from circulation through incision and reconstruction with tube graft or Y-prosthesis in inlay technique and consequent suture of the aneurysm sac by either transperitoneal or retroperitoneal approach.6
An alternative method, introduced and largely propagated by the Albany group,4, 5, 7 suggested that division of the proximal aorta, suture-closure of the distal aorta, outflow vessels, and end-to-end proximal to distal bypass achieves adequate aneurysm exclusion through a retroperitoneal approach. The authors suggested that the use of a posterolateral retroperitoneal approach for the repair of AAA in the technical modification described earlier, minimized operative dissection, and intraoperative blood loss in comparison to conventional transperitoneal aneurysm repair. In a prospective randomized study comparing the exclusion technique and endoaneurysmorrhaphy for the treatment of AAA, the exclusion and bypass techniques appeared to be an acceptable method, which was associated with less operative blood loss and fewer postoperative complications than those related to open aortic endoaneurysmorrhaphy. The authors concluded therefore that exclusion-bypass contributed to a smoother postoperative course of these patients. 8
Nevertheless, in another publication from the same group reporting long-term results of this exclusion and bypass approach for AAAs, the authors noted the risk of persistent aortic sac perfusion as diagnosed in 48 of their 1218 patients treated with this technique. The mean time to secondary intervention was 51 months (range, 2-113 months). Twenty-seven patients in this series had to be reoperated conventionally, seven of them because of rupture. Endovascular therapy was applied in six cases, leading to aneurysm exclusion in four of them (67% technical success).9
Chan et al.10 presented a series of six patients with persistent aneurysm sac perfusion after standard open repair. Leakage from the distal anastomosis was identified in five of them and from the proximal anastomosis in one of the reported cases. For the first time, the term “endoleak” was used for perfused aneurysm sacs after open repair.
However, patients treated with AAA exclusion and bypass constitute an individual patient cohort. The term “endoleak” seems appropriate to describe the mechanism of disease in these patients undergoing aneurysm exclusion.
In all three cases reported herein, the failure mode was nearly identical with the native iliac arteries feeding the aneurym sac. The exact pattern of the failure is difficult to be identified retrospectively. We presume that either a primarily insufficient suture-ligation or a loosening of the ligation with recanalization of the iliac artery on the affected side was the common factor of the failure.
Exclusion and bypass to treat AAA is not performed in our institution. In the case where such an operation needs to be performed, we suggest that the common iliac artery be stapled or divided on the side on which retrograde flow to the internal iliac artery needs to be preserved.
Endovascular repair was technically successful in all three patients by selective catheterization and occlusion of the feeding vessels of the aneurysm sac using coil embolization, deployment of occluding devices, and/or stent-graft implantation. After 30-42 months of follow-up, all patients are free of symptoms concerning the AAA and the aortic sac diameter decreased in two of three cases. The second patient had no regression of the maximal AAA diameter but no perfusion was present.
The mortality of conventional redo operation on the aorta after prior operation for AAA is reported as high as 17% on elective basis, reaching 24% in cases of emergency.11, 12 The introduction of endovascular techniques has significantly reduced morbidity and mortality after redo operations on the aorta. Herwaarden et al.13 reported 14 patients who underwent endovascular treatment of aortic pseudoaneurysms or iliac aneurysms occurring at a mean of 8.8 years after open aortic surgery. No perioperative deaths occurred and complete exclusion of the aneurysm sac was successful in all cases. One late and one early conversion were performed because of failed fixation between the stent-graft and the previous polyester graft, creating endotension in the thrombus of the aneurysm sac. Gawenda et al.14 reported in a comparative study of patients with para-anastomotic aneurysms of iliac arteries and aorta, both suitable for endovascular repair morphologically, that endovascular repair achieved less median blood loss and procedural as well as overall hospitalization time compared to open surgery.
Conclusion
AAAs operated with standard open repair should undergo follow-up examinations with sonography or CT in selected cases, especially when the open repair was performed using the exclusion and bypass technique. Persistent perfusion of the aneurysm sac after open repair as well as para-anastomotic aneuryms should be managed endovascularly whenever feasible.
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PII: S0890-5096(09)00334-3
doi:10.1016/j.avsg.2009.10.013
© 2010 Published by Elsevier Inc.
