Intra-Operative Gutter Endoleaks that Merritt Our Attention
Adam Tanious, Mathew Wooster, Martin Back, Murray L Shames
University of South Florida, Tampa, FL
EVAR with parallel grafts predisposes to gutter leaks and resultant endoleaks. The natural history and potential morbidity of these gutter leaks is unclear. We present our experience with intraoperative gutter endoleaks and strategies to determine which of these require intervention.
This is a retrospective review of all patients treated with parallel stent grafts from January 2010-September 2015. We reviewed all operative records and intraoperative angiograms as well as all post-operative imaging and secondary interventions. All gutter leaks were classified as low flow or high flow based on the rate of filling of the AAA sac. Adjunctive interventions to manage the gutter leaks were noted, as were all subsequent interventions for gutter leak and endoleak management.
Seventy-eight patients had 145 parallel stents placed over a 5-year period with an average of 1.8 stents per patient. Twenty-eight patients (36%) had gutter endoleaks diagnosed intra-operatively. 17 patients has adjunctive procedures to reduce gutter leaks prior to leaving the OR. Patients selected for treatment had gutters filling early during completion angiography and/or contrast enhancement of the aneurysm sac. Intra-operative treatment included repeat angioplasty of the proximal neck (n=14), proximal cuff placement (n = 6), endostaple placement (n=3), and one open conversion for proximal plication. Twenty-two patients (28%) left the operating room with low-flow/delayed/non-sac enhancing gutter endoleaks.
At 30 days there were 6 persistent gutter endoleaks diagnosed on CTA. Four of these endoleaks were diagnosed at completion angiography but were initially left untreated. Non-treatment resulted in spontaneous resolution of the gutter leaks in 64% (7/11) of patients. Two of the 6 post-operative endoleaks had attempts at treatment during the index procedure, while treatment had a success rate of 88% with 15 of 17 treated endoleaks having resolved either at the time of adjunctive treatment and/or by post-operative follow-up. There were 2 de-novo endoleaks not detected at the index procedure diagnosed at 6-month follow-up. Of the 8 total post-operative endoleaks, 5 required additional intervention due to sac enlargement (1 rupture) with a 100% success rate.
Statistical analysis showed that patients requiring intraoperative reversal with protamine were significantly more likely to leave the operating room with an endoleak (P = .0447). There were no significant predictors for having an intra-operative endoleak in a multivariate analysis. Multivariate analysis revealed that the only significant predictor of having a post-operative endoleak is leaving the operating room with an endoleak. Patients leaving the operating room without an endoleak are 1.8 times less likely to have a post-operative endoleak.
While gutter leaks are not uncommon after CH-EVAR, intra-operative treatment of gutter endoleaks has a high technical success rate for early phase, aneurysm sac enhancing leaks. Low-flow, non-sac enhancing gutter leaks have a high rate of
spontaneous resolution, thus observation is an acceptable strategy. Intra-operative treatment does not guarantee complete resolution and these patients still require post-operative monitoring.
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