I think this patient has type 1A endoleak that most probably due to severe angulation of the neck of the aneurysm.
This type of endoleak needs urgent intervention.
Options are:
Additional proximal cuff.
Balloon expanding coverd stent.
Endoanchors.
Coiling of the track.
F-EVAR.
Open repair.
mohammed mustafa taha
8 months ago
there is type 1a endoleak may be due to severely angulated neck
type 1 endoleak should be treated according to ESVS (level 1 B evidence)
treatment could be by Balloon molding of the proximal seal zone, placement of a proximal cuff, endostaples, proximal extension with a chimney approach, and conversion to a fenestrated endograft
final question before tomorrow, Can you summarise the results of
EVAR1 , EVAR 2 and improve trials ( these are very important trials and any vascular surgeon should know about these studies) and will these studies change your practice?
EVAR 1 published in 2010 showed that there’s decreased intra-operative mortality risk in the EVAR group than the OSR but in the long term follow up the risk was equal with the EVAR group has more risk of re-intervention.
EVAR 2 published in 2010 was comparing the patients who are ineligible for OSR into two groups EVAR or Conservative treatment, EVAR showed less mortality rate but higher re-intervention and higher cost.
Improve trial published in 2014 was comparing EVAR vs OSR in Ruptured AAA and showed both groups have similar outcomes
Do you routinely embolise inferior mesenteric artery or lumbar arteries before elective EVAR? is there any evidence to support that practice?
For patients with aorta-iliac aneurysm, do you routinely preserve the internal iliac artery or sacrifice it? what device do you use and what is the impact for embolisation of internal iliac artery? evidence ?
several studies shows that embolization of IMA decrease risk of Type 2 endoleak
“Preoperative Inferior Mesenteric Artery Embolization: A Valid Method to Reduce the Rate of Type II Endoleak after EVAR?Manunga, Jesse M. et al. Annals of Vascular Surgery, Volume 39, 40 – 47”
one of the two internal iliac arteries should be preserved in order to prevent buttock claudication or impotence in men by branched iliac device Smith MT, Gupta R, Jazaeri O, Rochon PJ, Ray CE Jr. Preservation of Internal Iliac Arterial Flow during Endovascular Aortic Aneurysm Repair Using the “Sandwich” Technique. Semin Intervent Radiol. 2013 Mar;30(1):82-6. doi: 10.1055/s-0033-1333657. PMID: 24436521; PMCID: PMC3700795.
Hi Remon that is type 1a endoleak you can see the sac filling 2 seconds after injection and not like the delayed picture we see for type 2 endoleak.
we discussed on the previous case options for intervention and you are all correct about ballooning, endoanchors, some centre used palmaz stent, chimney option with proximal extension.
Fenestaretd cuff surgeon modified or inner branch are options as well
custom made fenestrated for elective cases with type 1a endoleak after EVAR.
regarding completion angiography “last image”:
i can see the aneurysm sac is successfuly excluded,
no type 1 or type 2 endoleaks,
both internal iliac arteries preserved,
the left renal artery is preserved.
but the right is not “this was mentioned in the previous slide”
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Type 1 endoleak , possible stent caudal migration, need more proximal aortic cuff
Type 1 endoleak , possible stent caudal migration, need more proximal aortic cuff
type 1a endoleak
Needs intervention
I think this patient has type 1A endoleak that most probably due to severe angulation of the neck of the aneurysm.
This type of endoleak needs urgent intervention.
Options are:
there is type 1a endoleak may be due to severely angulated neck
type 1 endoleak should be treated according to ESVS (level 1 B evidence)
treatment could be by Balloon molding of the proximal seal zone, placement of a proximal cuff, endostaples, proximal extension with a chimney approach, and conversion to a fenestrated endograft
final question before tomorrow, Can you summarise the results of
EVAR1 , EVAR 2 and improve trials ( these are very important trials and any vascular surgeon should know about these studies) and will these studies change your practice?
EVAR 1 published in 2010 showed that there’s decreased intra-operative mortality risk in the EVAR group than the OSR but in the long term follow up the risk was equal with the EVAR group has more risk of re-intervention.
EVAR 2 published in 2010 was comparing the patients who are ineligible for OSR into two groups EVAR or Conservative treatment, EVAR showed less mortality rate but higher re-intervention and higher cost.
Improve trial published in 2014 was comparing EVAR vs OSR in Ruptured AAA and showed both groups have similar outcomes
another point for discussion,
Do you routinely embolise inferior mesenteric artery or lumbar arteries before elective EVAR? is there any evidence to support that practice?
For patients with aorta-iliac aneurysm, do you routinely preserve the internal iliac artery or sacrifice it? what device do you use and what is the impact for embolisation of internal iliac artery? evidence ?
several studies shows that embolization of IMA decrease risk of Type 2 endoleak
“Preoperative Inferior Mesenteric Artery Embolization: A Valid Method to Reduce the Rate of Type II Endoleak after EVAR?Manunga, Jesse M. et al. Annals of Vascular Surgery, Volume 39, 40 – 47”
one of the two internal iliac arteries should be preserved in order to prevent buttock claudication or impotence in men by branched iliac device
Smith MT, Gupta R, Jazaeri O, Rochon PJ, Ray CE Jr. Preservation of Internal Iliac Arterial Flow during Endovascular Aortic Aneurysm Repair Using the “Sandwich” Technique. Semin Intervent Radiol. 2013 Mar;30(1):82-6. doi: 10.1055/s-0033-1333657. PMID: 24436521; PMCID: PMC3700795.
Thanks Mina, did they mention certain diameter of IMA or lumbar arteries where you consider pre-EVAR embolisation?
IMA diameter >2.5 mm
Hi Remon that is type 1a endoleak you can see the sac filling 2 seconds after injection and not like the delayed picture we see for type 2 endoleak.
we discussed on the previous case options for intervention and you are all correct about ballooning, endoanchors, some centre used palmaz stent, chimney option with proximal extension.
Fenestaretd cuff surgeon modified or inner branch are options as well
custom made fenestrated for elective cases with type 1a endoleak after EVAR.
Oh sorry, I think there is some delayed filling of the sac,, may be endoleak.
regarding completion angiography “last image”:
i can see the aneurysm sac is successfuly excluded,
no type 1 or type 2 endoleaks,
both internal iliac arteries preserved,
the left renal artery is preserved.
but the right is not “this was mentioned in the previous slide”