SAVS - A new Technique using a Stent and a Plug for the Management of Persistent Type IIIc Endoleak Following Fenestrated Endovascular Aortic Repair (FEVAR): A Case Series

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A new Technique using a Stent and a Plug for the Management of Persistent Type IIIc Endoleak Following Fenestrated Endovascular Aortic Repair (FEVAR): A Case Series
Mohammad Alsarayreh, Mark A Farber, Federico E Parodi
University of North Carolina at Chapel Hill, Chapel hill, NC

Background:Fenestrated endovascular repair (FEVAR) has become a safe and effective option for the treatment of complex aortic aneurysms (CAA). Complications can arise including endoleaks. Type I and III endoleaks require prompt treatment after diagnosis. Type IIIc endoleaks occur between the fenestration and the bridging stent and is more common in 8x6 mm fenestration configurations. Although endoleaks may spontaneously resolve in some cases, most require secondary interventions to prevent further aneurysmal sac expansion and potential complications.
Methods:This case series presents four patients with persistent Type IIIc endoleaks following FEVAR for the treatment of CAA requiring a fenestration plugging technique to resolve. The maneuver involves the deployment of a stent and subsequent plug outside of the original bridging stent within the free space of the fenestration, offering a potential solution when conventional secondary interventions have failed.
Results:Four patients originally treated with a company-manufactured fenestrated endovascular grafts developed type IIIc endoleak from one renal artery (Table I). All patients underwent conventional type IIIc endoleak reintervention through either angioplasty (1 patient) or restenting (3 patients) of the target artery without resolution. Two patients had undergone two previous interventions, while the remaining two patients had only undergone one intervention before implementing this technique.In all 4 cases, the plugging intervention was performed percutaneously via bilateral femoral access, utilizing moderate sedation. All renal artery configurations were 8X6 designs, and occurred at a mean follow-up of 12.44 months after the index procedure (range: 6.90-20.52 months). The mean follow-up after the intervention is 2.94 months (range: 1.33 - 5.53 months). Technical success for the plugging procedure was 75% with one patient requiring an additional intervention to resolve the endoleak.The plugging technique begins with selective catheterization of the target vessel stent, and balloon protection while working within the free space of the fenestrations from the contralateral groin. Once the fenestrated free space is accessed, an iCast� stent (5x16 mm) is advanced into this space and deployed, followed by the placement of a plug within the new stent. The balloon in the original renal stent is then inflated to crush the new stent with the plug inside providing seal within the fenestration be reducing the effective fenestration diameter. A completion angiogram is performed to confirm stent patency and successful resolution of the endoleak.
Conclusion:Stenting and plugging the free space within the fenestration after fenestrated aortic repair is a promising technique for managing persistent Type IIIc endoleaks when traditional secondary interventions have failed. Further follow-up will be required to determine the mid- and long-term durability of the technique.
Table I: cases, stents used and follow-up



Case	Fen configuration	Artery treated		Stent deployed in artery	Number of prior SI	Technique stent	Plug used	f/u length from SI (months)	Sac size	Need for further SI
1	8x6 mm	RRA	5x22 iCast		2	5x16 mm iCast	8 mm AVP II	1.33	stable	No (resolved)
2	8x6 mm	LRA	7 x 22 mm iCast, & 7 x 22 mm iCast		2	5x16 mm iCast	6 mm AVP II	5.53	stable	Embolization for type III and type II endoleaks

3	8x6 mm	LRA	6 x 22 iCast & 6 x 22 iCast		1	5x16 mm iCast	6 mm AVP II	1.43	stable	No (resolved)

4	8x6 mm	RRA	6x22 iCast		1	5x16 mm iCast	6 mm AVP II	3.47	stable	No (resolved)

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