Rahimi Saum, Nassiri Naiem, Huntress Lauren, Crystal Dustin, Thomas Jones, Shafritz Randy
1 Division of Vascular Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
2 Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Vasc Endovascular Surg. 2018 May;52(4):249-254. doi: 10.1177/1538574418761269. Epub 2018 Feb 26.
Multiple endovascular techniques have been described for the treatment of persistent type II endoleaks (pT2ELs) causing aneurysm sac growth following endovascular aneurysm repair (EVAR). In the event of a failed endovascular procedure and a pT2EL, a consensus regarding further treatment is lacking, and the literature suggests repeated endovascular attempts are rarely successful. Herein, we propose an algorithm for definitive management of pT2ELs with persistent sac growth following EVAR.
A retrospective review of 29 patients who underwent treatment of persistent sac growth in the setting of pT2ELs was performed. Intervention methods were determined at the discretion of the operating surgeon. Aneurysmal sac enlargement was defined as a diameter increase > 5 mm, and persistent endoleak was defined as lasting greater than 6 months.
From 2000 to 2015, 917 EVAR procedures were performed at our institution. Isolated pT2ELs with sac enlargement were identified in 29 patients. Twenty-five patients underwent direct translumbar sac puncture and coiling and/or Onyx (Onyx, Plymouth, Minnesota) embolization of the culprit vessels. Thirteen (52%) of 25 patients had pT2EL after first endovascular intervention, and 10 (40%) of 25 patients failed 2 endovascular treatments. Of those 10, 7 displayed persistent aneurysmal sac growth and underwent a third embolization procedure. Type II endoleaks persisted in 6 patients; 3 patients were subsequently treated with laparotomy, ligation of lumbar vessels, sac exploration, and sac plication around the endograft. Technical success for this technique was 100%. During a mean follow-up of 38.4 months, no recurrent T2ELs, stent graft migration, and/or disjunction were observed.
We propose a new algorithm for the management of pT2ELs. If 2 endovascular procedures fail to control of the endoleak, repeat endovascular attempts are not recommended. Endovascular failure should be followed by laparotomy with surgical ligation of culprit feeding vessels followed by sac exploration and plication of the sac, and endoaneurysmorrhaphy.
已经描述了多种血管内技术用于治疗血管内动脉瘤修复术（EVAR）后导致动脉瘤囊增大的持续性II型内漏（pT2ELs）。如果血管内手术失败且存在pT2EL，目前对于进一步治疗缺乏共识，并且文献表明重复进行血管内治疗很少成功。在此，我们提出一种针对EVAR后伴有持续性囊增大的pT2ELs进行确定性治疗的算法。
对29例在pT2ELs情况下接受持续性囊增大治疗的患者进行回顾性研究。干预方法由主刀医生酌情决定。动脉瘤囊增大定义为直径增加>5mm，持续性内漏定义为持续超过6个月。
2000年至2015年，我们机构共进行了917例EVAR手术。29例患者被确定为孤立性pT2ELs伴囊增大。25例患者接受了直接经腰穿刺囊腔并对责任血管进行弹簧圈栓塞和/或使用奥尼克斯（Onyx，明尼苏达州普利茅斯）栓塞。25例患者中有13例（52%）在首次血管内干预后仍存在pT2EL，25例患者中有10例（40%）在两次血管内治疗后失败。在这10例患者中，7例显示动脉瘤囊持续增大并接受了第三次栓塞手术。6例患者II型内漏持续存在；3例患者随后接受了剖腹手术、腰血管结扎、囊腔探查以及在腔内移植物周围对囊腔进行折叠处理。该技术的技术成功率为100%。在平均38.4个月的随访期间，未观察到复发性T2ELs、支架移植物移位和/或脱节。
我们提出了一种新的pT2ELs治疗算法。如果两次血管内手术未能控制内漏，则不建议重复进行血管内治疗。血管内治疗失败后应进行剖腹手术，手术结扎责任供血血管，随后进行囊腔探查和囊腔折叠以及动脉瘤腔内缝合术。
