Southern Association For Vascular Surgery

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Endoleaks after fenestrated endovascular aneurysm repair
Carlos TIMARAN, Angie Garcia, Marilisa Soto-Gonzalez, david timaran
UT Southwetern Medical Center, Dallas, TX

Fenestrated endovascular aneurysm repair (FEVAR) has become an option for complex abdominal aortic aneurysms (AAAs).The occurrence of endoleaks is a common complication of endovascular aortic repair. With the use of fenestrated devices and stenting of the visceral vessels, the natural history of endoleaks may be affected. The aim of this study is to assess our institutional incidence and management of endoleaks after FEVAR using investigational devices.
A single institutional study was performed to assess the incidence of endoleaks after FEVAR using investigational devices under a physician sponsored investigational device exemption (IDE) granted by the US food and drug administration (FDA). Endoleaks originating from the visceral vessels with persistent flow, antegrade or retrograde, occurring at the main body fenestration and target vessel stent interface or from stent dislocation causing retrograde flow into the aneurysm sac; were defined as type 1c endoleaks. A retrospective review of a prospectively maintained database was performed. Preoperative demographic data, anatomic variables, and operative approaches and techniques were included in the study.
Over a 24-month period, 70 patients (52 male [74%] and 18 females [26%]) with a median age of 72 years (interquartile range [IQR], 69-77) underwent FEVAR using investigational devices. The median number of fenestrations was 4 (IQR,3-4). Endoleaks were found in 11 (16%) patients accounting for a total of 15 endoleaks distributed as follows: Type 1c 8 (53%), type 2 endoleaks 3(20%), type 3 endoleaks 3 (20%), and type 1b endoleaks 1(7%). The median time for endoleak re-intervention was 43 days (IQR, 34-224). Endovascular techniques were used in 14 cases (93%) as follows: type 1c: stenting distal to previous visceral ballon-expandable covered stents in 7 cases, in 1 case embolization of the right renal artery was required; type 2: translumbar embolization using Onyx®18 in 1 patient and in 2 cases transarterial embolization of the inferior mesenteric artery (IMA) using Onyx18®; type 3: 1 patient required embolization the SMA fenestration, and a second patient required the use the of a Palmaz stent to overlap the fenestrated device with the distal bifurcated device; type 1b: a limb extension was used to achieve distal sealing. One patient with type 3 endoleak underwent femoral-femoral bypass with a PTA graft. Re-interventions were successful in 73% of our patients. One patient was found with recurrent type1c endoleak from the left renal artery stent , a second patient was found with a recurrent type 1c endoleak from the right renal artery, and a third patient was found with a persistent type 2 endoleak. Patients with type 1c endoleaks were treated with stenting distal to balloon
expandable covered renal stents. IMA embolization was performed in a patient with type 2 endoleak.
Conclusion: The occurrence of endolaks after FEVAR using investigational devices is high accounting for 16%. At out institution, type 1c endoleaks were the most common, in all cases they were indication of intervention. The rate of type II endolaks was 4%, lower than reported for standard EVAR.

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