EVAR: Critical applied aortic morphology relevant to type-II endoleaks following device enhancement in patients with abdominal aortic aneurysms
Date
2004
Authors
Du Toit D.F.
Saaiman J.A.
Labuschagne B.C.J.
Vorster W.
Van Beek F.J.
Boden B.H.
Geldenhuys K.M.
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Journal ISSN
Volume Title
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Abstract
Endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is an established alternative option to conventional surgery for AAA, provided optimal anatomical morphology of the aneurysm sac, neck and outflow exists. In most documented series of EVAR, type-II endoleak occurrence is a universal procedural drawback. This is referred to as the Achilles heel of EVAR. This morphological study, addressing predominantly non-aneurysmal aortic anatomy, reveals the dyssynchronous origins of the renal ostia, ectopia of the superior mesenteric artery and median sacral artery, variations in the length of the infrarenal abdominal aorta, multiple mainstem renal arteries, and the presence of accessory renal arteries (in 13% of cadavers). Such potential vascular anomalies need careful consideration pre-operatively prior to EVAR. In a prospective, clinical study of EVAR in 163 patients over 60 months, using four different aortic stent devices, we demonstrated an intraprocedural type-II endoleak rate, before exclusion, of 3% (5/163). Most were related to patent lumbar arteries. An active policy of intraprocedural aneurysm pressure sac measurement and angiography was used to demonstrate type-I and type-II endoleaks, focusing on the applied anatomy of aortic side branches and variations. Selective intraprocedural coli embolisation and thrombin injection into the sac was utilised to thrombose persisting and large lumbar arteries that predisposed to retroleaks. We recorded a low incidence of persisting type-II endoleaks using this proactive treatment strategy by addressing variant aortic morphology and patent lumbar arteries during EVAR. One aneurysm-related death (0.6%) was observed due to late rupture after EVAR, and a single intraprocedural death was related to unpredictable aneurysm rupture. In conclusion, comprehensive anatomical knowledge of the abdominal aorta and its main collateral side branches, including variations, is a fundamental prerequisite if satisfactory and predictable results are to be achieved after EVAR, especially regarding prevention, diagnosis and treatment of type-II endoleaks. Intraprocedaral aneurysm sac pressure monitoring, coil embolisation and the use of injection of thrombin into the aneurysm sac of selected patients is useful in reducing the incidence of post-EVAR type-II persisting endoleaks.
Description
Keywords
thrombin, abdominal aorta, abdominal aorta aneurysm, adult, aged, aneurysm rupture, angiography, artery thrombosis, clinical trial, coil embolization, conference paper, endoleak, endovascular surgery, female, human, major clinical study, male, prospective study, renal artery, stent, superior mesenteric artery, vascular patency, Adult, Aged, Aged, 80 and over, Angioplasty, Aorta, Abdominal, Aortic Aneurysm, Abdominal, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation, Cadaver, Female, Humans, Incidence, Male, Middle Aged, Postoperative Complications, Prospective Studies, Prosthesis Failure, Treatment Outcome
Citation
Cardiovascular Journal of South Africa
15
4
15
4