Endoleaks 1, 3

1. ENDOLEAKSENDOLEAKS
Type I, IIIType I, III
Trellopoulos GeorgiosTrellopoulos Georgios
Vascular surgeonVascular surgeon
Gen. Hosp. “G. Papanikolaou”, ThessalonikiGen. Hosp. “G. Papanikolaou”, Thessaloniki

2. Endoleak
‘Blood flow outside the
lumen of the
endoluminal graft but
within the aneurysm sac
or adjacent vascular
segment treated by the
graft’.
White 1997

3. Classification of Endoleak
1a Proximal fixation site
1b Distal fixation site
1c Iliac occluder
Type 1 Graft-related
(fixation sites)

4. Classification of Endoleak
Type 2 Retrograde
branch flow
2a Inferior mesenteric
2b Lumbar

5. Classification of Endoleak
Type 3 Graft-related
(device integrity)
Type 3a Disjunction of
modular parts
Type 3b Fabric tear

6. Classification of Endoleak
Type 4 Graft-related
Fabric Porosity
Valid diagnosis within 30 days
after operation only

7. Endotension
‘Persistent or recurrent pressurisation of
the aneurysm sac (with or without
endoleak)’
Gilling-Smith 1999
Expanding sac

8. Diagnosis
 CT angiographyCT angiography
 MRAMRA
 DSADSA
 TriplexTriplex
CT technique
•Maximum 3mm thickness
•Two acquisitions
•Arterial and 5 minute delayed
•Diaphragm to groins

9. Indications
For 2nd
intervention
Risk factors for rupture – Multivariate
analysis
Risk ratio PRisk ratio P
Last diam. AAA 1.057 0.0028Last diam. AAA 1.057 0.0028
Proximal Type 1 3.998 0.0266Proximal Type 1 3.998 0.0266
Midgraft Type 3 7.474 0.0024Midgraft Type 3 7.474 0.0024
Migration 5.335 0.0156Migration 5.335 0.0156
Independent risk factors for rupture

10. Management Type I, III endoleaksManagement Type I, III endoleaks
StrategyStrategy
 Conservative ?Conservative ?
 BallooningBallooning
 Palmaz stentingPalmaz stenting
 CuffCuff
 Stent-graftStent-graft
 EmbolizationEmbolization
 Endostapling ?Endostapling ?

11. Type 1a
Type 1b
Ballon dilatation
+/- Palmaz stent
Embolization
? Extra-luminal banding?
Type 1 Endoleak
(no migration)
Balloon dilatation
Embolization

12. Management
Type 1 Endoleak
(with migration)
Type 1b
Extension cuff
+/- embolization
Covered stent
+/- embolization
Type 1a

13. Management
Type 3 Endoleak (with migration)
Cover stentCover stent
Conversion to aorto-uniliac with fem-femoral by-passConversion to aorto-uniliac with fem-femoral by-pass
Type 3a
Covered stent

14. CasesCases

15. Endoleak type IaEndoleak type Ia
conservative treatmentconservative treatment
CT examination after 9 days – endoleak Ia
Preoperative CT:
90% angulation of
the proximal neck

16. Endoleak type IaEndoleak type Ia
conservative treatementconservative treatement
CT examination 14 months after: no endoleak

17. Preoperative CT: endoleak type Ia
Endoleak type IaEndoleak type Ia
cuffcuff
CT examination after 11 days

18. Endoleak type IaEndoleak type Ia
embolizationembolization
1st
CT examination
2rd
CT, after 4 days:
endoleak Ia
CT examination
after embolization
Final CT, 5 days after:
no endoleak

19. Endoleak type IbEndoleak type Ib
iliac extensioniliac extension
Preoperative CT & DSA
images: endoleak Ib

20. Endoleak type IbEndoleak type Ib
iliac extensioniliac extension
CT examination after 3,5 months: no leakage

21. Endoleak type IbEndoleak type Ib
iliac extensioniliac extension
CT examination after 2 years and 9 months: endoleak from the right limb
Final CT after placement of iliac
extension: no leakage

22. Endoleak type Ia, Ib, IIEndoleak type Ia, Ib, II
Preoperative CT: endoleak type Ia, II

23. Endoleak type Ia, Ib, IIEndoleak type Ia, Ib, II

24. 2nd
DSA examination, after 10 days: Occlusion of the type Ia

25. CT examination after 10 days: persistence of the II endoleak

26. CT examination after 7 months: persistence of endoleak type II

27. DSA examination, after CT: endoleak type Ib
Final CT examination after 1 month: no leakage

28. Endoleak type IbEndoleak type Ib
conversion to openconversion to open
Preoperative CT: acute AAA

29. CT & DSA images 10 days after the procedure: Endoleak type Ib

30. Endoleak type IbEndoleak type Ib
conversion to openconversion to open
CT examination 3 months after extension placement
4 years after the procedure, migration of the left limb

31. EUROSTAR 2006EUROSTAR 2006
in 2846 patientsin 2846 patients
 Type I endoleakType I endoleak ~ 2% in 12 months~ 2% in 12 months
 Type III endoleak ~ 1%Type III endoleak ~ 1%
 Treated by transfemoral approach: 60%Treated by transfemoral approach: 60%
 Secondary intervention in 8,7% at 12 monthsSecondary intervention in 8,7% at 12 months
after procedure. 1/3 of them for endoleak type Iafter procedure. 1/3 of them for endoleak type I
& III& III

32. EUROSTAREUROSTAR
Group C (diam > 6,4cm)Group C (diam > 6,4cm)
Angulation of the proximal neckAngulation of the proximal neck
Diameter of the proximal neckDiameter of the proximal neck
Type I endoleak at completion angiography wasType I endoleak at completion angiography was
9,9% vs 3,7 in group A (diameter < 5,5)9,9% vs 3,7 in group A (diameter < 5,5)
Risk factors and prevention
• Short or angulated infrarenal aortic neck are the most significant
preoperative risk factors for type I endoleak
• Neck length < 20mm and diameter > 28mm can lead to an endograf
migration and endoleak
• Aortic neck dimension and quality of proximal and distal fixation site are
the most critical factors for prevention of endoleak
•Two of three endoleaks that are seen at the time of the
discharge seal during the first month after the procedure

33. Close proximity of theClose proximity of the
distal end of thedistal end of the
stent graft to thestent graft to the
iliac bifurcationiliac bifurcation
seems to provideseems to provide
stability againststability against
migration.migration.
The importance of iliacThe importance of iliac
fixation in prevention offixation in prevention of
stent graft angulation.stent graft angulation.
Christofer Zarins et al JVS
2006
27% of the patients27% of the patients
required secondaryrequired secondary
procedures (98procedures (98
procedures).procedures).
87% of them were87% of them were
treated endovascularly.treated endovascularly.
(8 years experience)(8 years experience)
J P Bequemin
et al JVS 2004

34. ConclusionsConclusions
1. It is critical to select the appropriate patient1. It is critical to select the appropriate patient
Neck length > 10mmsNeck length > 10mms
Neck diameter < 30mmsNeck diameter < 30mms
Neck angulation < 75 degreesNeck angulation < 75 degrees
Oversize by 20%Oversize by 20%
2. Security of the proximal graft fixation is the most2. Security of the proximal graft fixation is the most
important factor in preventing acute and late typeimportant factor in preventing acute and late type
I endoleaks.I endoleaks. It is recommended that theIt is recommended that the
endograft is placed as close to the renal arteriesendograft is placed as close to the renal arteries
as possible and extended to the hypogastricas possible and extended to the hypogastric
arteriesarteries

35. ConclusionsConclusions
3. 60 – 85% of the type I and III endoleaks3. 60 – 85% of the type I and III endoleaks
can be treated with endovascularcan be treated with endovascular
approach.approach.
4.4. Critical point: the surveillance of theCritical point: the surveillance of the
patients using CTApatients using CTA

36. Thank you for your attention!