Eur J Vasc Endovasc Surg 21, 339 343 (2001) doi:10.1053/ejvs.2001.1333, available online at http://www.idealibrary.com on Influence of Treatment of Type II Leaks on the Aneurysm Surface Area F. Liewald 1, C. Ermis 2,J.Görich 2, G. Halter 1, R. Scharrer-Pamler 1 and L. Sunder-Plassmann 1 1 Department of Thoracic and Vascular Surgery, 2 Department of Radiology, University of Ulm, Ulm, Germany Objective: to determine whether interventional treatment of type II endoleaks leads to a decrease in aneurysm surface area. Material and Method: type II endoleaks were detected in a group of 14 male patients (median age: 70.2 years) following endovascular repair of a total number of 160 infrarenal aneurysms of the abdominal aorta. The surface area of the aneurysm was determined by computed tomography (CT) pre- and postoperatively and at subsequent follow-up examinations. If type II endoleaks were documented at CT, patients underwent treatment by means of coil embolisation. Results: interventional treatment resulted in successful occlusion of type II endoleaks in eight patients. One of the cases exhibited spontaneous occlusion. Occlusion was associated with an average decrease in aneurysm surface area of 3.3 cm 2 (p=0.01). In one of these patients, treatment resulted in a temporary occlusion of the endoleak, also with associated decrease in aneurysm size. After recurrence of the type II endoleak, however, the patient experienced an increase in aneurysm surface area. In the remaining four patients the type II endoleaks persisted, resulting in a non significant increase in aneurysm surface area. Conclusion: only complete occlusion of endoleaks results in decrease in the size of the aneurysm sac. Because of endotension and the risk of rupture we favour an early interventional treatment of type II endoleaks. Key Words: Endoleak; Aneurysm; Stentgraft; Endovascular repair. Introduction persistent endoleak, there is general consensus regarding the necessity of treatment in type I and type Endoleaks are defined as persistent blood flow within III endoleaks as well in cases of increases in the surface the aneurysm sac despite implantation of an endograft area of the aneurysm associated with all types of prosthesis. This complication is reported in 2 47% of endoleak. 5,9 Treatment options range from coil embolisation patients undergoing endograft procedures. 1 4 and implantation of additional stents or Based on the classification proposed by White et al., cuffs to conversion to open surgical repair. The question endoleaks can be assigned to four main groups 5 8 remains whether endoleaks resulting from retendoleaks (Table 1). rograde perfusion of the aneurysm sac via spinal or Because of the potential for rupture in cases of mesenteric vessels (type II) should undergo interventional therapy. 10 12 Table 1. Classification of endoleaks. 6 8 The objective of the present study was to determine Type Definition whether changes in aneurysm surface area following therapy of type II endoleaks permitted conclusions I Perigraft leaks: persistent blood flow at either the regarding the interventional treatment of endoleak in central or distal graft end due to inadequate sealing of the prosthesis. these patients. II Retrograde perfusion of the aneurysm sac via spinal vessels or the inferior mesenteric artery. III Midgraft leak resulting from disconnection of modular systems or from graft defects. IV Graft-porosity leaks caused by contrast medium Material and Methods diffusion in the early phase. From September 1995 to January 2000 a total of 160 patients underwent implantation of endograft prostheses for repair of infrarenal aneurysms of the ab- Please address all correspondence to: F. Liewald, Department of Thoracic and Vascular Surgery, University of Ulm, Steinhövelstraße dominal aorta (AAA). Of these patients, 14 (all males, 9, 89075 Ulm, Germany. average age: 70 years) developed type II endoleaks 1078 5884/01/040339+05 $35.00/0 2001 Harcourt Publishers Ltd.
340 F. Liewald et al. Table 2. Clinical data of patients with type-ii endoleaks. (Postoperative surface area was measured at days 3 5 postoperatively. Final examination was performed at 6 36 months postoperatively median follow-up period: 18 months.) Patient Source of the endoleak Clinical Interventional Preoperative Postoperative Surface area at number course result surface area in surface area in final follow-up cm 2 cm 2 examination in cm 2 1 Iliolumbar ce Successful 23.3 22.8 23.3 2 Lumbar s Successful (s) 18.9 19.2 17.7 3 Lumbar ce Successful 16.9 17.7 12.2 4 Median sacral r Successful 16.6 16.3 15.5 5 Inferior mesenteric artery r Successful 19.6 20.8 19.6 6 Lumbar ce Successful 18.9 20.0 10.7 7 Lumbar ce Successful 20.4 20.4 17.7 8 Inferior mesenteric artery ce Successful 35.7 34.1 27.2 9 Lumbar r Successful 22.3 25.2 21.0 10 Iliolumbar r Recurrent 19.9 18.8 18.4 11 Inferior mesenteric artery r Unsuccessful 17.6 17.3 18.1 12 Lumbar r Unsuccessful 17.3 18.5 19.2 13 Lumbar (type II) and at distal r Unsuccessful 28.7 30.6 29.2 anchoring site (type I) 14 Lumbar ce Unsuccessful 12.6 12.6 14.6 s=spontaneous resolution; r=recurrent application of coil embolisation; ce=coil embolisation. In this patient, a type-ii endoleak was successfully occluded; the patient later experienced another, secondary type-ii endoleak. Table 3. Type of used stentgrafts. cephalad end of the stentgraft to differentiate proximal Type of used Patient number Device perigraft leaks. Finally, both internal iliac arteries (10- stentgraft configuration ml manual injection of contrast) and the superior mesenteric artery (25 ml of contrast infused at 5 ml/ Vanguard 1, 4 Bifurcated Talent 3, 6, 8, 9, 10, 13 Bifurcated s) were selectively visualised. If the selective cath- Corvita 2 Bifurcated eterisation of the contralateral internal iliac artery Gore excluder 5, 11, 12, 14 Bifurcated proved unsuccessful, angiography was repeated the AneuRx 7 Bifurcated next day from the contralateral side. Using this protocol, if reperfusion of the aneurysmal sac from the (8%). In 13 patients only type-ii endoleaks were obwas superior mesenteric artery (SMA) through the IMA served, while one other (no. 13) suffered from a comthen identified on CT and confirmed on angiography, bined endoleak (types I and II) (Table 2). an attempt to embolise the endoleak was made. Five different endograft prostheses were used (Table The SMA was catheterised with a 5-F catheter (Cobra 3). The first attempt at treatment of persistent type-ii or Sidewinder) and 2500 units of heparin were adendoleaks was made 3 months following implantation ministered intra-arterially to avoid arterial thrombosis. of the endograft prosthesis. Follow-up examinations Then a Tracker 18 (Rehaforum, Cologne, Germany) for determination of aneurysm surface area and decatheter or Rapid Transit (Cordis, Haan, Germany) coaxial tection of endoleaks were performed at 3-monthly was advanced to the leak and 2- to 8-mm- intervals using contrast enhanced computed tomomany) diameter metal coils (Boston Scientific, Hilden, Gergraphy (CT) imaging (Elscint, Twin, Haifa, Israel). In were delivered. As a rule, the guidewire re- 10 patients the type II endoleaks were first diagnosed commended by the catheter company was used, but by the first postoperative CT. Patient nos 1, 8, 14 in very tortuous arteries the very flexible 0.016-in revealed a type II endoleak with the CT control after Terumo guidewire (Terumo, Frankfurt, Germany) was 3 months. With patient no. 3 an endoleak could be advantageous. Moreover, embolisation of the entire detected by the first postoperative CT, which could aneurysm sac to the site of entry is advised to prevent not be seen any more with 3-month control. After 6 persistent leak from communicating lumbar arteries. months the endoleak was evident again, so that a final In patients with leaks supplied by the lumbar arteries, coil embolisation resulted in occlusion of the endoleak. the vessels small diameters precluded a direct ap- In cases of persistent endoleak, patients underwent proach to the feeding artery. In such leaks the collateral intra-arterial digital subtraction angiography (DSA) in vessel of the iliolumbar artery was occluded with order to identify the feeder vessels. This was followed minicoils from the internal iliac artery as peripherally by angiography with a Cobra or Sidewinder catheter as possible. 11,12 (Boston Scientific, Hilden, Germany) positioned at the For each patient a total amount of 5 until 31 coils
Type II Endoleaks Following Stent Graft Placement 341 was necessary to close the endoleak. Seven patients underwent recurrent interventions. The time for interventional therapy was usually 60 75 min and did not exceed 90 min. The surface of the aneurysm was measured on a workstation using the axial CT slice that diplayed the greatest sac dimensions. It was defined as an ellipsoid surface with the longest diameter of the aneurysm being the major axis (D1) of the ellipsoid, whereas the diameter perpendicular to it was used as the minor axis (D2). The surface was calculated according to the formula: π D 1 /2 D 2 /2. All aneurysms were regarded as having an ellipsoid shape to simplify the calculation. Evaluation of measurements was performed using the log-rank test for p=0.05. Measurements were performed by two independent radiologists. The median follow-up period was 18 months. Results The primary goal of every definitive treatment of aneurysms is to protect the patient from death sec- ondary to rupture. Findings assembled to date through the Eurostar Data Program show that both the in- cidence of endoleaks and increases in the diameter of the aneurysm sac correlate positively with the risk of rupture of aortic aneurysms which have been treated with endograft implantation. 13 The risks associated with type I and type III endoleaks appear to be more significant. With regard to type II endoleaks, both our own findings and those reported in a study by Resch et al. suggest that while there may not be any significant increase in aneurysm diameter or surface area, there is also no reduction. 14 In our opinion, however, one can only speak of satisfactory repair of an aortic aneurysm when reduction in the diameter or surface area of the aneurysm can be demonstrated. There are three reasons for considering a reduction in the size of the aneurysm sac to be the most reliable criterion of success: Definite occlusion of patients endoleaks was possible in nine of 14 cases of type II endoleak (group I). One of these cases exhibited spontaneous occlusion, while in the remaining eight patients the endoleaks proved amenable to coil embolisation. In one patient (no. 10), occlusion of a type II endoleak was initially successful, with concomitant decrease in the surface area of the aneurysm sac from 19.9 to 17.7 cm 2. After 6 months, however, a secondary type II endoleak was observed, with an increase in aneurysm surface area from 17.7 to 18.4 cm 2. In the remaining four cases (group II), patients endoleaks persisted despite attempts at interventional therapy. Three of these patients underwent multiple interventional attempts. In patients with complete occlusion of their en- doleaks (group I), CT follow-up examinations revealed a significant average decrease in aneurysm surface area from 21.4±5.5 to 18.1±5.2 cm 2 (p=0.01). The respective median values stood at 19.6 (range: 16.5 35.2) and 17.7 (range: 10.2 27.2) cm 2 (p=0.01) after a median 18-month follow-up period. In group II, which consisted of patients in whom complete occlusion of the endoleak proved impossible, we observed an average increase in the surface area of patients aneurysms from 19.1±5.9 to 20.3±5.4 cm 2 (p=0.67 not significant). The respective median values increased from 17.5 (range: 12.6 28.7) to 18.7 (range: 14.6 29.2) cm 2. The difference in changes in the surface area of patients aneurysms between the group with successfully treated type II endoleaks and those in whom Surface at the level of maximum aneurysm size (cm 2 ) Changing aneurysm morphology after endovascular repair: relation to leakage 23 22 21 20 19 18 17 16 15 pre OP post OP After secondary intervention Fig. 1. Postoperative surface area was measured at days 3 5 post- operatively. Final examination was performed at 6 36 months postoperatively median follow-up period 18 months. (Η) Successfully treated leakage (n=9); (Φ) persistent leak (n=5). p=0.01. treatment of endoleaks proved unsuccessful was stat- istically significant (p=0.01; Fig. 1). The increase in surface area in patients with persistent leaks was not significant (p=0.67). There was no complication related to the embolisation procedure. Discussion (1) Endoleaks may sometimes escape detection, particularly in those cases in which there is no demonstrable outflow phenomenon. (2) Based on Laplace s Law, it is primarily the pressure (endotension) and not the flow within an aneurysm sac which is responsible for increases in size. 14 (3) Long-term observations reported by Resnikoff et
342 F. Liewald et al. al. 16 have shown that, among patients in whom an guided puncture of the aneurysm in one patient AAA was treated with an aorto-iliac bypass and proved unsuccessful. occlusion of the aneurysm sac, those patients with An alternative to coil embolisation could be the continued perfusion of the aneurysm sac via collateral intraoperative insertion of an absorbable gelatinous feeder arteries and no decrease in aneurysm sponge into the aneurysmal sac via the occluder in- diameters exhibited a high risk of rupture. In a troducer sheath. 16 group of 831 patients, persistent endoleak was The only type of embolisation material used in observed in 2% of cases; of those patients with our series was metal coils. Although metal coils are persistent endoleak, fully 40% eventually ex- expensive and must sometimes be used in large perienced rupture. amounts (up to 31 coils have been required in our patient series), other techniques, including the use of All of these findings underscore the importance of tissue adhesives, are associated, in our opinion, with adequate therapy of leaks and documentation of re- a greater risk of neurological complications. ductions in aneurysm surface area by means of regular In conclusion, findings in the present study underfollow-up. In our series of 14 patients with type II score the significant reduction in aneurysm surface endoleaks, successful occlusion was possible in eight area in patients in whom type-ii endoleaks are succases (plus one patient with spontaneous closure). cessfully treated using interventional techniques. This was associated with a significant reduction in Long-term results will show if the reduction in the aneurysm surface area. size of the aneurysm sac can be considered to be a In one of these patients we observed a spontaneous definite criterion for the success of endograft repair of occlusion within 3 months. This possibility of spon- infrarenal aneurysms of the abdominal aorta, in order taneous occlusion might prompt the question of to avoid a rupture. whether our policy of aggressive treatment of endoleaks may actually represent overtreatment. On one side the possible limitations of our study include minimal errors in surface area calculation in aneurysms References with unusual morphologies, as well as lack of longterm outcomes and small study population. As a measefficacy of transfemoral endovascular aneurysm management: a 1Broeders IAMJ, Blankensteijn JD, Gvakharia A et al. The ure of change in aneurysmal size we preferred to use study on size changes of the abdominal aorta during mid-term a calculated aneurysmal surface vs. maximum sac follow-up. Eur J Vasc Endovasc Surg 1997; 14: 84 90. diameter in order to receive a more exact geometrical 2 Malina M, Ivancev K, Chuter TAM et al. Changing aneurysmal morphology after endovascular grafting: relation to leakage or approximation. On the other hand, based on what was persistent perfusion. J Endovasc Surg 1997; 4: 23 30. said above regarding the issue of endotension with 3Matsumura JS, Pearce WH, McCarthy WJ, Yao JS. Reduction constant diameters of patients aneurysm sacs, it is in aortic aneurysm size: early results after endovascular graft placement. EVT Investigators. J Vasc Surg 1997; 25: 113 123. our opinion that occlusion of endoleaks represents 4Matsumura JS, Moore WS,. For the Endovascular Technologies Investigators. Clinical consequences of periprosthetic enhanced security in the treatment of aneurysms. In five patients type II endoleaks persisted despite leak after endovascular repair of abdominal aortic aneurysms. J Vasc Surg 1998; 27: 606 613. attempted interventional treatment. In one of these 5White GH, Yu W, May J. Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, patients there was temporary occlusion of an endoleak; the occurrence of a secondary type II endoleak, how- incidence, diagnosis and management. J Endovasc Surg 1997; 4: 152 186. ever, was documented 6 months later. Increases in the 6White GH. Assessment and classification of endoleak and endotension. In: Branchereau A, Jacobs M, eds. Surgical and Ensurface area of the aneurysm sac were observed in four patients; in one patient (no. 13), this resulted in dovascular Treatment of Aortic Aneurysms. Amsterdam: Marseille- EVC, 2000: 131 139. conversion to conventional open surgery. One other 7White GH, May J, Waugh RC, Yu W. Type I and Type II patient is currently awaiting conversion to open surendoluminal endoleaks: a more useful classification for reporting results of AAA repair. J Endovasc Surg 1998; 5: 189 191. gery. The remaining two patients remain under ob- 8White GH, May J, Petrasek P et al. Type III and type IV servation. endoleak: toward a complete definition of blood flow in the sac The transarterial embolisation of endoleaks with after endoluminal AAA repair. J Endovasc Surg 1998; 5: 305 309. metal coils is a relatively safe technique. To date, 9Parodi JC, Barone A, Piraino R et al. Endovascular treatment of abdominal aortic aneurysms: Lessons learned. J Endovasc Surg we have observed none of the complications such as 1997; 4: 102 110. paraplegia reported in the literature. 15 Despite use of 10 Görich J, Rilinger N, Sokiranski R et al. Leakages after en- a superselective catheter, primary occlusion of the dovascular repair of aortic aneurysms: Classification based on findings at CT, angiography and radiography. Radiology 1999; endoleak is not always possible. Multiple embolisation 213: 767 772. attempts were required in seven patients. Direct CT 11 Görich J, Rilinger N, Sokiranski R et al. Treatment of leaks
Type II Endoleaks Following Stent Graft Placement 343 after endovascular repair of aortic aneurysms. Radiology 2000; of abdominal aortic aneurysm after endovascular repair does 215: 414 420. not lead to progressive change in aneurysm diameter. J Vasc 12 Görich J, Rilinger N, Krämer SC et al. Angiography of leaks Surg 1998; 28: 242 249. after endovascular repair of infrarenal aortic aneurysms. AJR 15 Resnikoff M, Darling R, Chang BB et al. Fate of the excluded 2000; 174: 811 814. abdominal aortic aneurysm sac: longterm follow-up of 831 13 Harris PL. Intermediate and late complications of endovascular patients. J Vasc Surg 1996; 24: 851 855. AAA repair in surgical and endovascular treatment of aortic 16 Walker SR, Macierewicz J, Hopkinson BR. Rendovascular aneurysms. In: Branchereau A, Jacobs M, eds. Amsterdam: Futura AAA repair: prevention of side branch endoleaks with thrompublishing company, EVC-Symposium, 2000: 155 162. bogenic sponge. J Endovasc Surg 1999; 6: 350 353. 14 Resch T, Ivancev K, Lindh M et al. Persistent collateral perfusion