Zone Chairperson Role and Responsibilities New updated.pptx
Management of endoleaks after evar asvs 2013
1. Management of Endoleaks after EVAR
Michel Makaroun MD
Co-Director UPMC Heart and Vascular Institute
Professor and Chief, Division of Vascular Surgery
University of Pittsburgh School of Medicine
3. Type I
Attachment leak
Type II
Branch flow
Type III
Defect in graft or
modular disconnection
Type IV
Fabric porosity
The Different Types of Endoleaks
4. There is almost uniform consensus about
Type I and III Endoleaks
They are serious and associated with a
significant risk of rupture!
Should be treated whenever feasible:
either with
Endovascular Salvage or
Open Conversion
8. World Review of Ruptures after EVAR
55% (129/235) of All Ruptures
are due to Type I endoleaks
38 of the ruptures in the first 30 days
9. Intrasac Pressure Measurements
Before Exclusion
Mean Pressure: 75 mmHg
After EVAR with Type I
Mean Pressure: 111 mmHgBefore Implantation Type I endoleak
10. Earliest EVAR Tube Experience
Parodi first 50 patients (1995)
5 Type I endoleaks (10%) : 3 proximal 2 distal
4 died by 8 months, one from Rupture @2 months
20% Mortality from Rupture 1st
year !
11. Earliest EVAR Bifurcated Experience
Chuter first 41 patients (1996)
9 Type I endoleaks (22%)
2 Type I died within 3 days from rupture
22% Mortality from Rupture!
12. Early Experience proved Type I Endoleaks to be serious.
ALL Type I Endoleaks have since been treated when feasible
at original procedure or when discovered!!
1. Incidence has decreased significantly
2. Very few type I endoleaks are monitored conservatively
Small endoleaks missed at completion angiography
Endoleaks difficult to manage by endovascular means
in sick patients with limited life expectancy
13. Endovascular Rx of Type I Endoleaks
Extensions with Stent Grafts
High pressure balloons
Increase Radial Force by Palmaz Stents
Endostapling
Extension Simple and effective but can be limited by
1. Renals close to the proximal end
2. Essential internal iliac artery
In those situations
Coiling of the track may work
Or Coverage of the Renals with chimneys
Rarely Open Conversion is required
Higher Mortality and morbidity
14. Procedural Type I Endoleak Treated by Ballooning
Pre deployment Type I Endoleak Ballooning
No more endoleak
15. Procedural Type I Endoleak Treated by Extension
Pre deployment Type I Endoleak Extension
No more endoleak
16. Procedural Type I Endoleak Treated with Palmaz
Type I Endoleak Palmaz Stent No Endoleak
17. Procedural Type I Endoleak Treated by Endostaples
Courtesy of Jim Joye DO
18. Late Type I Endoleaks
Can be due to Migration
Aneurysmal degeneration of neck
Enlargement of Iliac arteries
Angulation
19. Treated with New Endograft inside first one
Endovascular Rx of Proximal Type I Endoleak
after Proximal Migration
20. Endovascular Rx of Distal Type I
from Iliac Degeneration
7 years post Ancure:
Distal Type I Endoleak
Right Limb
Endoleak
Excluder
14.5 x 7cm
Extension
No more
Endoleaks
Treated by Extension
21. Endovascular Rx of Proximal Type I Endoleak
after Proximal Migration
3 years post AneuRx:
Migration and Proximal
Type I
No More
Endoleaks
Treated by Extension and Palmaz Stent
22. Endovascular Rx of Proximal Type I Endoleak
after Proximal Migration
Treated by Extension and Left renal stent
Type I
Old Type II
coiled
NO Type I
No Room
To extend
23. Endovascular Rx of Proximal Type I Endoleak
with renal coverage and chimneys
Aneurysm
neck wall
Poor deployment and Type I Treated with suprarenal
Extension and 2
Failed
Extension
Palmaz
Staples
24. Coiling of Distal Type I
6 months post Tube Ancure
Distal Type I
Graft
Endoleak
Coils
1 Month Post Coiling 5.8 cm
25. Coiling of Distal Type I
1 year post coiling 4.6 cm 2 years post coiling 3.4 cm
5 year post coiling 2.8 cm4 year post coiling 2.8 cm
26. Type I
Open Conversion
Does not always require complete Explantation
Operative Mortality: 5-10%
High Morbididty
Conversion To Open Repair
28. Fabric Tear and Type III Endoleak
Fabric Tear from Wall stent in Ancure Rx with Excluder Limb
6 years after Implantation
29. Limb Disconnection and Type III endoleak
Rt Limb Disconnection in a Lifepath Rx with Excluder Limb
6 years after Implantation
30. How about Type II Endoleaks?
The opinions here are much more divided !
31. The Majority of Endoleaks are Type II
0
20
40
60
80
100
None Type I Type II Type III Type IV Type
Indet
%subjectsevaluated
12 Mos
24 Mos
36 Mos
48 Mos
60 Mos
Excluder Regulatory Trial: 5 year Chart
32. 12 Mos
Type II Total % Type II Total % Type II Total %
Talent 10 159 6.2%* 1 118 0.80% 0 113 0.00%
Lifepath 4 57 7.00%
Excluder 13 86 15.10% 8 55 14.50% 5 36 13.90%
Zenith 19 124 15.30% 3 43 7.00%
AneuRx 34 327 10.40% 29 210 13.80% 13 92 14.10%
Ancure 27 295 9.20% 15 213 7.00% 2 121 1.60%
Total 107 1048 10.20% 56 639 8.80% 20 362 5.50%
24 Mos 36 Mos
Occurs with all Grafts in 14% (10-20%) of patients
Prevalence decreases to 5-10% between 1-3 years
Sheehan MK, Makaroun MS et al J Vasc Surg 2006;43:657-61
Incidence Similar for ALL Endografts
33. Diagnosis of Type II Endoleaks
CT and Duplex agree in many cases on Endoleak.
Source of Endoleak ???
35. Source can be difficult to determine
Some endoleaks are very complex
90 x 91 mm AAA
MB Nov 2003
MB Dec 2003
Type I Endoleak ??
Or is it IMA Type II ??
CT Diagnosis of Type II Endoleaks
38. 1. WHEN TO TREAT?
The answer has changed steadily over the years
gradually favoring a more conservative approach
The current recommendation:
Rx confirmed Type II Endoleaks ONLY when
associated with AAA sac Enlargement !
Also eliminates many unnecessary re-interventions
39. Evidence suggests that Type II endoleaks
have a relatively Benign Natural History !
0
10
20
30
40
50
60
70
80
90
OP D/C 3m 6m 12m 24m 36m
Excluded
Endoleaks
No Interventions until 6 Months
2/3 resolve spontaneously
by 6 months
Makaroun et al Eur J Vasc Endovasc Surg 1999;18:185-90
UPMC 1999
40. Spontaneous resolution can occur Late
Year 1. May 2003
Type II Endoleak
Year 2. May 2004
Type II Endoleak
Year 3. May 2005
No Endoleak
Late Spontaneous Resolution (3 Years)
42. 486 Patients with 90 Type II Endoleaks (18.5%)
61% sealed spontaneously in 6 months
Only 6% experienced enlargement > 5mm
J Vasc Surg 2004;39:306-13
43. 965 Patients with 154 Type II Endoleaks (16%)
75% seal spontaneously in 5 years (KM analysis)
Only 8.4% experienced enlargement > 5mm
J Vasc Surg 2006;44:453-59
44. So Should we Ignore Type II Endoleaks?
Probably not!
45. Review of 270 Aneurysm Ruptures after EVAR
Endoleaks the cause of rupture in 160 patients
Type I or III in 114 Patients
Type II in 23 Patients
Eur J Vasc Endovasc Surg 2009;37:15-22
46. Type II Endoleaks
Usually run a benign course
But can rarely result in rupture
Should ONLY be treated when associated with
AAA enlargement!
Caveat: Increasing Sac Size is an unproven surrogate
for the potential of future rupture but quite likely
47. 2. How to do it?
There is no consensus as to the best way to treat
Type II Endoleaks, as they can be very different
from each other and can be very complex to treat.
48. Approaches to Type II Endoleaks
Observation
Laparoscopic clipping of branches
Open Surgical Conversion
Partial or Complete
Endovascular Approaches !!
49. Endovascular Rx of Type II Endoleaks
Multiple Branch Vessels involved
IMA
Multiple sets of Lumbars
Other branches
Large Nidus
Diagnosis is usually suspected by
Duplex or CT but has to be
confirmed at angiography!
Principle of Endo RX
Obliterate the feeding vessels
and if possible the nidus
Three Different Approaches
Trans-Arterial catheterization:
More technically demanding but
potentially more effective
Translumbar puncture
Transcaval direct access
Rx Nidus. Difficult to get vessels
Occluding Agents
Glue
Onyx
Thrombin
Coils
50. Onyx and Glue are liquid agents that help fill
nidus but very expensive and complicate FU
ONYX
18 m later size increased from 9 to 14 cm
and presented with a leaking AAA
51. Onyx and Glue are liquid agents that help fill
nidus but very expensive and complicate FU
Type III
Disconnection
Type IB
Endoleak
Unrecognized
Type II
Endoleak
Poorly coiled
52. 2. How I do it
Technical Notes
Trans-arterial Coaxial System
Micro-catheters
Coils
Can deliver very long coils if needed (Interlocks)
Use Saline flush for short ones instead of coil pushers
Make sure it is occluded
Proximal lumbars (L1-L3) near impossible to reach
53. Int Iliac coils
6 Fr Sheath in Internal Iliac
5 Fr angled Catheter
Microcatheter
56. Coiling of Type II IMA Endoleak
IMA endoleak treated by coiling
57. Type II Endoleaks Can be Complex: Case AH
June 07: Lumbar
Type II endoleak
Microcatheter
Access
Lumbars Coiled
No endoleak
58. AH Oct 07: Endoleak still present/ AAA larger
Oct 07
Persistent
Endoleak
More
Feeders
Renegade
Micro
Catheter
Access to
AAA Sac
Complex Endoleak
Nidus and
Branches
Coiled
Some endoleaks are complex and
require multiple interventions
59. Trans-Arterial Access Not Always Available
OW March 2012
Persistent
Endoleak
67x70 mm
Type II Endoleak
No Transarterial Access Right
No Transarterial Access left
60. Trans-Lumbar Approach Reasonable Alternative
OW March 2012
Patient prone
Shiba needle/ .018 wire
Puncture endoleak
Exchange for Stiff wire
6 Fr 30 cm sheath
Catheter
Eliminate Nidus
62. Trans-Caval Approach Useful in Some Patients
Patient Supine
Trans-Caval approach
with a Rosch-Uchida
catheter
Angiogram
Direct embolization of
Nidus and branches
Removal of catheter
and completion
cavogram
63. 3. Does it Work?
A qualified YES!
Of course conversions (both partial and complete) do
work but associated morbidity is high
Endovascular interventions are tedious and will work
in most, if operator is experienced and persistent
64. 3. Does it Work?
Unfortunately, Very little long term data exists!
It is easy to make claims of effectiveness since:
a) Many interventions were carried too early when
most endoleaks would have resolved spontaneously
b) Many techniques obstruct future imaging
c) No clear endpoint of effectiveness: Size of AAA
65. UPMC experience 1995- 2003
All Trans-Arterial coiling
Endoleaks only treated if persistent > 6 months
Success: No leaks and stable or shrinking AAA sac
FU: Mean 18 months
J Vasc Surg 2004;40:430-4
66. Results of Coiling
28 patients
Follow-up 1-60mos
Clinical Success (82%)
15/19 (79%) Type II
8/9 (89%) Type I
Procedural Morbidity 0%
Procedural Mortality 0%
67. Type II Endoleaks: Results of Coiling
19 patients
21 attempts
2 patients required more
than one intervention
Can be very complex
15 successful
1 IMA
7 pure lumbar
7 combined
68. 3 Lumbar Coils
Two years later
Two interventions later
Coils Not Occlusive
Multiple
Coils added
Till Occlusion
69. Several sources coexist in some complex cases
Type II
Lumbar
1 Year Year 2
Type I
Distal
Year 3
Type II
IMA
70. Endovascular techniques can be used safely and
effectively to Treat Endoleaks after EVAR
Type I and Type III should almost always be treated
when discovered
Treatment of Type II should be reserved to patients
with sac enlargement
Open Conversions may be necessary but carry a
higher morbidity and mortality
Summary
Notas do Editor
Note: this slide shows each type of endoleak separately.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.
Image is of a competitor’s graft.
The above images were taken from cases implanted at the Hospital of the University of Pennsylvania by Dr’s Baum and Fairman. They document the angiographic images you will see where there is some form of graft failure. The explanted graft is a competitor’s graft that has a tear in it.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.
Type II Endoleaks are “anatomy related” and due to patent lumbar arteries or IMA branches. Currently there is debate as to whether patent lumbar arteries and IMA’s should be coil embolized prior to Endograft placement.