HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Daniel Zimpfer Ernst Wolner Michael Grimm Martin Czerny Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zimpfer, D. Articles by Czerny, M. Search for Related Content PubMed PubMed Citation Articles by Zimpfer, D. Articles by Czerny, M. Related Collections Great vessels

Ann Thorac Surg 2007;83:664-666
© 2007 The Society of Thoracic Surgeons

---

Case Reports

Treatment of Type V Endoleaks by Endovascular Redo Stent-Graft Placement

^a Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria
^b Department of Angiography and Interventional Radiology, University of Vienna Medical School, Vienna, Austria

Accepted for publication June 20, 2005.

^_* Address correspondence to Dr Czerny, Waehringer Guertel 18-20, Vienna, Austria, A-1090. (Email: bypass{at}eunet.at).

	Abstract

Top Abstract Introduction Case Reports Comment References

 
Continuous enlargement of the aneurysmal sac after endovascular stent-graft treatment of thoracic aortic aneurysms due to graft wall porosities (type V endoleak) is a novel problem. Two patients having undergone prior endovascular stent-graft placement of a thoracic aortic aneurysm presented with a continuous enlargement of the aneurysmal sac without a detectable endoleak. Both patients underwent redo stent-graft placement. Subsequently, shrinkage of the aneurysmal sac could be observed. Therefore endovascular redo stent-graft placement may represent an effective means in treating type V endoleaks.

	Introduction

Top Abstract Introduction Case Reports Comment References

 
Conventional surgical repair of thoracic aortic aneurysms continues to carry a substantial rate of mortality and morbidity especially in the elderly [1]. Endovascular stent-graft placement, due to its less invasiveness, has developed as a safe and effective treatment modality in various diseases of the descending aorta and more recently in several diseases of the aortic arch [2, 3].

Despite encouraging short-term and mid-term results, persistence or new formation of any kind of endoleaks remain a challenging issue. Clinical relevance and treatment modalities of type I to IV endoleaks have been well defined in both thoracic and abdominal aortic aneurysms. However, few reports are available with regard to type V endoleaks to date [4, 5].

The aim of this case report was to evaluate whether or not endovascular redo stent-graft placement is effective in inducing aneurysmal sac shrinkage in patients with type V endoleaks.

The definitions of endoleaks are as follows: type I endoleaks are defined as attachment site leaks (type Ia at the proximal attachment site and type Ib at the distal attachment site). Type II endoleaks were defined as branch leaks without attachment site connection. Type III endoleaks were defined as junctional leaks between stent grafts if more than one graft was used. Type IV endoleaks were defined as graft wall porosities. Type V endoleaks were defined as an increase in maximum aneurysm diameter without detectable endoleaks [6].

	Case Reports

Top Abstract Introduction Case Reports Comment References

 
Patient 1
In April 2001, a 57-year-old man was admitted to our department with a contained rupture of a proximal descending aortic aneurysm with a maximum diameter of 9.9 cm, having undergone previous conventional infrarenal aortic replacement. A transfemoral insertion of a 34/200 mm Gore stent graft (early generation) was performed. Completion of a computed tomographic (CT) scan revealed no signs of endoleaks.

During a follow-up of 1,275 days, aneurysm sac diameter increase was 4.1 cm, reaching 14.0 cm without any signs of endoleak in follow-up CT scans. In December 2004, redo endovascular stent-graft placement was performed with a 34/200 mm Gore stent graft (new generation). Intraarterial angiography performed prior to redo stent-graft placement was not able to detect any kind of endoleak. Subsequently, completion of a CT scan in March 2005 revealed recurring aneurysmal sac shrinkage of 1.5 cm.

Patient 2
In October 2000, a 59-year-old patient was admitted to our department with a chronic posttraumatic descending thoracic aortic aneurysm with a maximum diameter of 6.9 cm. Endovascular stent-graft placement was performed with a 37/200 mm Gore stent graft (early generation). Completion of a CT scan revealed no signs of endoleaks.

In February 2002, segmental resection of the liver was performed due to hepatocellular carcinoma. During a follow-up of 932 days, aneurysm sac diameter increase was 1.6 cm, reaching 8.5 cm without any signs of endoleaks in follow-up CT scans. In November 2004, a transfemoral endovascular stent-graft insertion of a 40/150 mm Gore stent-graft (new generation) was performed. Intraarterial angiography performed prior to redo stent-graft placement was not able to detect any kind of endoleak. Subsequently, the completion of a CT scan in March 2005 revealed recurring aneurysmal sac shrinkage of 1.3 cm.

	Comment

Top Abstract Introduction Case Reports Comment References

 
These case reports confirm that endovascular redo stent-graft placement is effective in inducing sac shrinkage in patients with type V endoleaks. Extended application of this approach may add in treating this particular subgroup of patients as an alternative to conventional repair.

Midterm durability of endovascular stent-graft placement in atherosclerotic aortic aneurysms involving the arch as well as the descending aorta seems promising, as the rate of endoleak formation with consecutive need for reintervention is acceptably low. However, if endoleaks do occur, a straight forward approach is warranted to prevent late complications.

Type V endoleaks (ie, endotension) have been defined as a continuous enlargement of the aneurysmal sac without signs of endoleak formation. Incidence and fate of type V endoleaks in the abdominal aorta are well defined. In contrast, type V endoleaks in the thoracic aorta are a novel problem. In the EuroStar registry, the prevalence of type V endoleaks was 5.4% (abdominal aorta). There are several causes for the development of type V endoleaks, including pressure transmission to the aneurysmal sac at the ends of the graft by thrombus layered between the wall and the graft, pressure transmission through the graft wall, and exudation through the graft material (a known problem in early generation stent grafts). Exudation through the graft material is the most likely cause for endoleak formation in this series as both patients were initially treated with early generation grafts. As these grafts have been widely used in the past, we will face increasing numbers of patients with type V endoleaks in the near future [7].

Type V endoleaks that are left untreated may lead to continuous enlargement and consecutive rupture of the aneurysmal sac [8]. Therefore management strategies have to be discussed. Conventional surgical treatment remains an option in these patients; however, the primary intention of endovascular stent-graft placement in these patients is to avoid conventional surgical treatment. There are no up-to-date reports on the usefulness of laparoscopic fenestration as well as thrombin injections in patients with type V endoleaks. Treatment by means of placing secondary cuffs has been reported, however there are no long-term data. We have chosen to perform redo-stent graft placement based on the hypothesis of enforcement of the initial endovascular prosthesis with consecutive inhibition of further seroma formation within the aneurysmal sac. Redo-stent graft placement was safely performed in both patients, and we experienced no difficulties (eg, stent dislocation) during redo stent-graft placement. Redo stent-graft placement was successful in terms of inducing aneurysmal sac shrinkage. As we used new generation stent grafts for redo stent-graft placement in both patients, we feel that the risk for re-expansion of the aneurysmal sac is reduced to a minimum.

In summary, endovascular redo stent-graft placement may represent an effective means in treating type V endoleaks by inducing aneurysmal sac shrinkage. Extended application of this approach may aid in treating this particular subgroup of patients as an alternative to conventional repair. Further observations are warranted to reconfirm durability of this approach.

	References

Top Abstract Introduction Case Reports Comment References

 

1. Kazui T, Washiyama N, Muhammad BA, et al. Improved results of atherosclerotic arch aneurysm operations with a refined technique J Thorac Cardiovasc Surg 2001;121:491-499.[Abstract/Free Full Text]
2. Dake MD, Miller DC, Semba CP, et al. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
3. Czerny M, Cejna M, Hutschala D, et al. Stent-graft placement in atherosclerotic descending thoracic aortic aneurysms: midterm results J Endovasc Ther 2004;11:26-32.[Medline]
4. Cho JS, Dillavou ED, Rhee RY, et al. Late abdominal aortic aneurysm enlargement after endovascular repair with the Excluder device J Vasc Surg 2004;39:1236-1242.[Medline]
5. Thoo CH, Bourke BM, May J. Symptomatic sac enlargement and rupture due to seroma after open abdominal aortic aneurysm repair with polytetrafluoroethylene graft: implications for endovascular repair and endotension J Vasc Surg 2004;40:1089-1094.[Medline]
6. Chaikof EL, Blankensteijn JD, Harris P, et al. Reporting standards for endovascular aortic aneurysm repair J Vasc Surg 2002;35:1048-1060.[Medline]
7. Sanchez LA, Faries PL, Marin ML, et al. Chronic intraaneurysmal pressure measurement: an experimental method for evaluating the effectiveness of endovascular aortic aneurysm exclusion J Vasc Surg 1997;26:222-230.[Medline]
8. Veith FJ, Baum RA, Ohki T, et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference J Vasc Surg 2002;35:1029-1035.[Medline]

This article has been cited by other articles:

				J. K. Hoang, S. Martinez, and L. M. Hurwitz MDCT Angiography of Thoracic Aorta Endovascular Stent-Grafts: Pearls and Pitfalls Am. J. Roentgenol., February 1, 2009; 192(2): 515 - 524. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Daniel Zimpfer Ernst Wolner Michael Grimm Martin Czerny Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zimpfer, D. Articles by Czerny, M. Search for Related Content PubMed PubMed Citation Articles by Zimpfer, D. Articles by Czerny, M. Related Collections Great vessels