- Email: [email protected]
Early Post-EVAR Rupture in a Patient with Early Type II Endoleak: A Borderline Treatment
Journal Pre-proof Early post – EVAR rupture in a patient with early type II endoleak: A borderline treatment Christiana Anastasiadou, M.D, Sotiris Giannakakis, M.D, PhD, Anastasios Papapetrou, M.D, PhD, George Galyfos, M.D, Msc, PhD, George Kastrisios, M.D, Chrisostomos Maltezos, M.D, PhD PII:
S0890-5096(19)30963-X
DOI:
https://doi.org/10.1016/j.avsg.2019.10.099
Reference:
AVSG 4766
To appear in:
Annals of Vascular Surgery
Received Date: 15 September 2019 Revised Date:
30 October 2019
Accepted Date: 31 October 2019
Please cite this article as: Anastasiadou C, Giannakakis S, Papapetrou A, Galyfos G, Kastrisios G, Maltezos C, Early post – EVAR rupture in a patient with early type II endoleak: A borderline treatment, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.10.099. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
1
1
Early post – EVAR rupture in a patient with early type II endoleak: A borderline
2
treatment
3
Christiana Anastasiadou M.D, Sotiris Giannakakis M.D, PhD, Anastasios Papapetrou M.D,
4
PhD, George Galyfos M.D, Msc, PhD, George Kastrisios M.D, Chrisostomos Maltezos M.D,
5
PhD
6
Department of Vascular Surgery, General Hospital of Attica “KAT”
7 8
Corresponding author: Anastasiadou Christiana
9
Email address: [email protected]
10
14561, Greece
11
Fax: +302132086455 tel: +302132086069
12
Email addresses (rest authors):
13
[email protected]
14
[email protected] [email protected]
Address: Nikis 2, Kifisia, Athens, P.O
[email protected]
[email protected]
15 16
Abstract:
17
Purpose: The detection of type II endoleak one month after endovascular aneurysm
18
repair (EVAR) is usually neglected or considered benign. Aim of this report is to present a
19
case of post-EVAR rupture, due to type II endoleak, and discuss on pathophysiology and
20
differential diagnosis.
21
Case report: We present a case of a 67-year old male who was treated with EVAR for
22
an asymptomatic abdominal aortic aneurysm and four months later, he presented with a
23
contained rupture due to a type II endoleak. The patient was treated conservatively without
24
any intervention with satisfying result.
2
25 26
Conclusion: We are demonstrating conservative management as a valid therapeutic option for patients presenting with a contained post-EVAR rupture.
27 28
Keywords: type V endoleak, endotension, type ii endoleak, post-evar, rupture, post-
29
implantation syndrome, conservative
30 31
Acknowledgement: Informed consent has been obtained from the patient for publication of
32
the case report and accompanying images. This case report was also presented at L.I.V.E
33
Symposium which was held in Larissa (Greece) 9-11 May 2019.
34
Conflict of interest: None
35 36
Introduction:
37
Despite recent improvements in technology, and familiarization with endovascular
38
techniques, endovascular aneurysm repair (EVAR) is still associated with complications that
39
may either require re-intervention or lead to rupture. Persistent sac pressurization may occur
40
from high-flow endoleaks (type I or III) or transmission of systemic pressure through the
41
intraluminal thrombus (endotension or type V endoleak). However, type II endoleaks remain
42
the most common type, and they are usually attributed to backfilling of the aneurysmal sac
43
from patent aortic branches such as lumbar arteries or the inferior mesenteric artery. Type II
44
endoleaks seem to appear in 10-20% of all post-EVAR CT-scans although they resolve
45
spontaneously within six to twelve months in 80% of the cases.
46
suggest an intervention when a type II endoleak causes sac expansion of more than 10mm.
47
(SVS 2017 recommendation 2C, ESVS 2018, recommendation 2B) [3,4] In case of a contained
48
rupture, however, the clinical presentation is not definitive, and a misdiagnose is possible.
49
Aim of this report is to demonstrate that in rare cases of post-EVAR rupture with adequate
[2]
Current recommendations
3
50
proximal and distal graft sealing and no active extravasation, conservative therapy may be
51
considered as a valid strategy.
52 53
Case report:
54
A 67-year old male patient with an asymptomatic abdominal aortic aneurysm
55
(maximum diameter 6.2cm) underwent an EVAR procedure using an Anaconda endograft
56
(Vascutek Corporation). His medical history included diabetes mellitus and chronic
57
prostatitis. Postoperatively, he presented a post-implantation syndrome (PIS), including fever
58
(temperature of 38ºC) and an increase in serum inflammation markers (White blood cells
59
[WBC] 14000x103/ul, C-reactive protein [CRP] 7,6 mg/dl). The patient was discharged four
60
days later being afebrile and under single antiplatelet therapy.
61
One month later, a computed tomography angiography (CTA) revealed: (i) a small
62
type II endoleak, (ii) inferior mesenteric artery (IMA) patency (proximal diameter 2.2mm),
63
(iii) patency of three lumbar arteries (proximal diameter 0.9-1.1mm) and (iv) stable size of
64
aneurysm sac (maximum diameter 6.2cm). (Fig.1) Three months later, the patient presented at
65
the emergency department of another hospital with fever (temperature of 39 ºC) and lower
66
abdominal pain radiated to the back. At the time of the presentation, the laboratory tests were
67
indicative of urinary tract infection (positive urinalysis, erythrocyte sedimentation rate [ESR]:
68
99ml/h, WBC: 6800x103/ul
69
Hematocrit [Ht]: 36.6%). As a result, he was admitted to a urology department and was
70
treated with fosfomycin (3g/daily). The patient was discharged a few days later being afebrile
71
and under fosfomycin therapy for four weeks.
57%Neu, procalcitonin [PCT]: 0.03 ng/ml, CRP 5.72 mg/dl,
72
However, the patient presented again at our vascular surgery department two days
73
after the previous discharge complaining of a residual vague lumbar pain. A new CTA was
74
performed revealing not only an aneurysm sac expansion (maximum diameter 6.5cm) but also
75
a contained rupture adjacent to the left psoas. (Fig 2, video 1, video 2). Since the patient was
4
76
haemodynamically stable without any hemoglobin decrease (compared to the previous
77
admission) we decided to admit the patient for observation and withdraw aspirin. Further
78
laboratory assessment included measurement of serum inflammation markers, blood cultures
79
and urinalysis which were all negative. Repeated haemoglobin measurements did not show
80
any significant variation. Therapy with fosfomycin3g/daily and meropenem 6g/daily was
81
extended for one week based on the recent urinary tract infection and the history of chronic
82
prostatitis.
83
Additionally, the patient underwent a digital subtraction angiography (DSA) after
84
three days in order to exclude any occult endoleak. However, in the delayed phase, a small
85
type II endoleak was demonstrated arising from a patent lumbar artery. (Fig. 3, Video 3).
86
Finally, the patient was discharged one week later, after complete resolution of symptoms and
87
with stable hemoglobin levels. One year later, the patient remains in good health,
88
asymptomatic, with total regression of the aneurysm sac (Figure 4, Video 4),
89 90
Discussion:
91
Considering disease progression, we assume that a pressurization of the aneurysm sac
92
occurred during the first month in this case which led to contained rupture. Differential
93
diagnosis included urinary tract infection, renal colic, pancreatitis, psoas abscess and post-
94
EVAR rupture. Labaratory tests (negative blood cultures, positive urinalysis) were indicative
95
of urinary tract infection and vascular imaging was not performed at that time. However,
96
CTA was performed a few days later in our department under the indication of persistent back
97
pain.
98
Regarding pathophysiology, type II endoleak was the most obvious risk factor in this
99
case. Literature suggests that factors increasing the risk of a persistent or “malignant” type II
100
endoleak include a patent IMA, a large number or diameter of patent lumbar arteries
101
(especially L3 and L4 lumbar arteries), a large endoleak cavity between inflow and outflow
5
[5]
102
arteries combined with ongoing anticoagulation.
In the present case, there was more than
103
one branch patent although no aneurysm sac expansion was observed after the first
104
postoperative month. Given that ruptures from type II endoleak are rare, we decided to
105
perform DSA in order to exclude an occult type I endoleak. In addition, DSA would facilitate
106
transarterial superselective catheterization of the IMA or any embolization. Eventually, IMA
107
was not visualized, and the remaining lumbar artery was considered small and insignificant.
108
[3,4,5]
109
which could have contributed to contamination of the endograft. However, none of the
110
laboratory tests or imaging was suggestive of endograft infection.
Other aggravating factor for rupture could be the inflammation (urinary tract infection)
111
Another speculation is that the rupture was somewhat correlated with a type V
112
endoleak (endotension) in the contect of PIS. According to literature, the Anaconda endograft
113
is associated with more intense PIS compared to other endografts.
114
suggested that the volume of new-onset thrombus is significantly correlated with the peak
115
postoperative temperature (P < 0.05). the increase in WBC count (P < 0.05), CRP level (P <
116
0.001), and IL-6 level (P < 0.05).
117
new-onset thrombus and that transmission of systemic pressure through this thrombus
118
(videlicet type V endoleak) could lead to rupture cannot be proved in this patient and thus,
119
this is a limitation of the present case report.
[6]
[6]
Kakisis et al, have
However, the theory that this syndrome can produce
120 121
Conclusion:
122
Clinical presentation of post-EVAR rupture is not typical in the absence of high-flow
123
endoleak and it may occult. We demonstrate conservative management and close observation
124
as valid option in such patients presenting with contained rupture. Finally, we highlight the
125
need for further studies to identify a possible correlation of PIS with type V endoleak as well
126
as early identification of high-risk type II endoleak.
127
6
128
References:
129
1. Panagiotis Kougias, Jean Bismuth, Tam T. Huynh et al. Symptomatic Aneurysm
130
Rupture Without Bleeding Secondary to Endotension 4 Years After Endovascular
131
Repair of an Abdominal Aortic Aneurysm J ENDOVASC THER 2008;15:702–705
132
2. Brewster DC, Jones JE, Chung TK et al. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Ann Surg. 2006;244(3):426–438.
133 134
3. F.L. Moll J.T. Powell, G. Fraedrich et al Management of Abdominal Aortic
135
Aneurysms Clinical Practice Guidelines of the European Society for Vascular
136
Surgery Eur J Vasc Endovasc Surg (2011) 41, S1-S58
137
4. Elliot L. Chaikof Dalman, Mark K. Eskandari et al. The Society for Vascular
138
Surgery practice guidelines on the care of patients with an abdominal aortic
139
aneurysm. J Vasc Surg 2018; 67:2-77.
140
5.
Andrew Brown, Greta K Saggu, Matthew J Bown et al. Type II endoleaks:
141
challenges and solutions. Vascular Health and Risk Management 2016:12 53–63
142
6. John D. Kakisis, Konstantinos G. Moulakakis, Constantine N. Antonopoulos
143
et al. Volume of new-onset thrombus is associated with the development of
144
postimplantation syndrome after endovascular aneurysm repair J Vasc Surg
145
2014;60:1140-5.
146 147
Figure legends:
148
Fig. 1. CT angiography (one month postoperatively) which reveals a type II endoleak (note
149
the patency of three lumbar arteries and inferior mesenteric artery)
150
Fig. 2. CT angiography (four months postoperatively) which reveals rupture of the aortic wall
151
without extravasastion. Please notice that there is no aortic-wall thickening, no air around the
152
graft and no soft tissue greater than 5 mm between psoas and the stent graft, fluid collection.
153
Fig. 3. Digital subtraction angiography revealed a small type II endoleak in delayed phase.
S0890-5096(19)30963-X
DOI:
https://doi.org/10.1016/j.avsg.2019.10.099
Reference:
AVSG 4766
To appear in:
Annals of Vascular Surgery
Received Date: 15 September 2019 Revised Date:
30 October 2019
Accepted Date: 31 October 2019
Please cite this article as: Anastasiadou C, Giannakakis S, Papapetrou A, Galyfos G, Kastrisios G, Maltezos C, Early post – EVAR rupture in a patient with early type II endoleak: A borderline treatment, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.10.099. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
1
1
Early post – EVAR rupture in a patient with early type II endoleak: A borderline
2
treatment
3
Christiana Anastasiadou M.D, Sotiris Giannakakis M.D, PhD, Anastasios Papapetrou M.D,
4
PhD, George Galyfos M.D, Msc, PhD, George Kastrisios M.D, Chrisostomos Maltezos M.D,
5
PhD
6
Department of Vascular Surgery, General Hospital of Attica “KAT”
7 8
Corresponding author: Anastasiadou Christiana
9
Email address: [email protected]
10
14561, Greece
11
Fax: +302132086455 tel: +302132086069
12
Email addresses (rest authors):
13
[email protected]
14
[email protected] [email protected]
Address: Nikis 2, Kifisia, Athens, P.O
[email protected]
[email protected]
15 16
Abstract:
17
Purpose: The detection of type II endoleak one month after endovascular aneurysm
18
repair (EVAR) is usually neglected or considered benign. Aim of this report is to present a
19
case of post-EVAR rupture, due to type II endoleak, and discuss on pathophysiology and
20
differential diagnosis.
21
Case report: We present a case of a 67-year old male who was treated with EVAR for
22
an asymptomatic abdominal aortic aneurysm and four months later, he presented with a
23
contained rupture due to a type II endoleak. The patient was treated conservatively without
24
any intervention with satisfying result.
2
25 26
Conclusion: We are demonstrating conservative management as a valid therapeutic option for patients presenting with a contained post-EVAR rupture.
27 28
Keywords: type V endoleak, endotension, type ii endoleak, post-evar, rupture, post-
29
implantation syndrome, conservative
30 31
Acknowledgement: Informed consent has been obtained from the patient for publication of
32
the case report and accompanying images. This case report was also presented at L.I.V.E
33
Symposium which was held in Larissa (Greece) 9-11 May 2019.
34
Conflict of interest: None
35 36
Introduction:
37
Despite recent improvements in technology, and familiarization with endovascular
38
techniques, endovascular aneurysm repair (EVAR) is still associated with complications that
39
may either require re-intervention or lead to rupture. Persistent sac pressurization may occur
40
from high-flow endoleaks (type I or III) or transmission of systemic pressure through the
41
intraluminal thrombus (endotension or type V endoleak). However, type II endoleaks remain
42
the most common type, and they are usually attributed to backfilling of the aneurysmal sac
43
from patent aortic branches such as lumbar arteries or the inferior mesenteric artery. Type II
44
endoleaks seem to appear in 10-20% of all post-EVAR CT-scans although they resolve
45
spontaneously within six to twelve months in 80% of the cases.
46
suggest an intervention when a type II endoleak causes sac expansion of more than 10mm.
47
(SVS 2017 recommendation 2C, ESVS 2018, recommendation 2B) [3,4] In case of a contained
48
rupture, however, the clinical presentation is not definitive, and a misdiagnose is possible.
49
Aim of this report is to demonstrate that in rare cases of post-EVAR rupture with adequate
[2]
Current recommendations
3
50
proximal and distal graft sealing and no active extravasation, conservative therapy may be
51
considered as a valid strategy.
52 53
Case report:
54
A 67-year old male patient with an asymptomatic abdominal aortic aneurysm
55
(maximum diameter 6.2cm) underwent an EVAR procedure using an Anaconda endograft
56
(Vascutek Corporation). His medical history included diabetes mellitus and chronic
57
prostatitis. Postoperatively, he presented a post-implantation syndrome (PIS), including fever
58
(temperature of 38ºC) and an increase in serum inflammation markers (White blood cells
59
[WBC] 14000x103/ul, C-reactive protein [CRP] 7,6 mg/dl). The patient was discharged four
60
days later being afebrile and under single antiplatelet therapy.
61
One month later, a computed tomography angiography (CTA) revealed: (i) a small
62
type II endoleak, (ii) inferior mesenteric artery (IMA) patency (proximal diameter 2.2mm),
63
(iii) patency of three lumbar arteries (proximal diameter 0.9-1.1mm) and (iv) stable size of
64
aneurysm sac (maximum diameter 6.2cm). (Fig.1) Three months later, the patient presented at
65
the emergency department of another hospital with fever (temperature of 39 ºC) and lower
66
abdominal pain radiated to the back. At the time of the presentation, the laboratory tests were
67
indicative of urinary tract infection (positive urinalysis, erythrocyte sedimentation rate [ESR]:
68
99ml/h, WBC: 6800x103/ul
69
Hematocrit [Ht]: 36.6%). As a result, he was admitted to a urology department and was
70
treated with fosfomycin (3g/daily). The patient was discharged a few days later being afebrile
71
and under fosfomycin therapy for four weeks.
57%Neu, procalcitonin [PCT]: 0.03 ng/ml, CRP 5.72 mg/dl,
72
However, the patient presented again at our vascular surgery department two days
73
after the previous discharge complaining of a residual vague lumbar pain. A new CTA was
74
performed revealing not only an aneurysm sac expansion (maximum diameter 6.5cm) but also
75
a contained rupture adjacent to the left psoas. (Fig 2, video 1, video 2). Since the patient was
4
76
haemodynamically stable without any hemoglobin decrease (compared to the previous
77
admission) we decided to admit the patient for observation and withdraw aspirin. Further
78
laboratory assessment included measurement of serum inflammation markers, blood cultures
79
and urinalysis which were all negative. Repeated haemoglobin measurements did not show
80
any significant variation. Therapy with fosfomycin3g/daily and meropenem 6g/daily was
81
extended for one week based on the recent urinary tract infection and the history of chronic
82
prostatitis.
83
Additionally, the patient underwent a digital subtraction angiography (DSA) after
84
three days in order to exclude any occult endoleak. However, in the delayed phase, a small
85
type II endoleak was demonstrated arising from a patent lumbar artery. (Fig. 3, Video 3).
86
Finally, the patient was discharged one week later, after complete resolution of symptoms and
87
with stable hemoglobin levels. One year later, the patient remains in good health,
88
asymptomatic, with total regression of the aneurysm sac (Figure 4, Video 4),
89 90
Discussion:
91
Considering disease progression, we assume that a pressurization of the aneurysm sac
92
occurred during the first month in this case which led to contained rupture. Differential
93
diagnosis included urinary tract infection, renal colic, pancreatitis, psoas abscess and post-
94
EVAR rupture. Labaratory tests (negative blood cultures, positive urinalysis) were indicative
95
of urinary tract infection and vascular imaging was not performed at that time. However,
96
CTA was performed a few days later in our department under the indication of persistent back
97
pain.
98
Regarding pathophysiology, type II endoleak was the most obvious risk factor in this
99
case. Literature suggests that factors increasing the risk of a persistent or “malignant” type II
100
endoleak include a patent IMA, a large number or diameter of patent lumbar arteries
101
(especially L3 and L4 lumbar arteries), a large endoleak cavity between inflow and outflow
5
[5]
102
arteries combined with ongoing anticoagulation.
In the present case, there was more than
103
one branch patent although no aneurysm sac expansion was observed after the first
104
postoperative month. Given that ruptures from type II endoleak are rare, we decided to
105
perform DSA in order to exclude an occult type I endoleak. In addition, DSA would facilitate
106
transarterial superselective catheterization of the IMA or any embolization. Eventually, IMA
107
was not visualized, and the remaining lumbar artery was considered small and insignificant.
108
[3,4,5]
109
which could have contributed to contamination of the endograft. However, none of the
110
laboratory tests or imaging was suggestive of endograft infection.
Other aggravating factor for rupture could be the inflammation (urinary tract infection)
111
Another speculation is that the rupture was somewhat correlated with a type V
112
endoleak (endotension) in the contect of PIS. According to literature, the Anaconda endograft
113
is associated with more intense PIS compared to other endografts.
114
suggested that the volume of new-onset thrombus is significantly correlated with the peak
115
postoperative temperature (P < 0.05). the increase in WBC count (P < 0.05), CRP level (P <
116
0.001), and IL-6 level (P < 0.05).
117
new-onset thrombus and that transmission of systemic pressure through this thrombus
118
(videlicet type V endoleak) could lead to rupture cannot be proved in this patient and thus,
119
this is a limitation of the present case report.
[6]
[6]
Kakisis et al, have
However, the theory that this syndrome can produce
120 121
Conclusion:
122
Clinical presentation of post-EVAR rupture is not typical in the absence of high-flow
123
endoleak and it may occult. We demonstrate conservative management and close observation
124
as valid option in such patients presenting with contained rupture. Finally, we highlight the
125
need for further studies to identify a possible correlation of PIS with type V endoleak as well
126
as early identification of high-risk type II endoleak.
127
6
128
References:
129
1. Panagiotis Kougias, Jean Bismuth, Tam T. Huynh et al. Symptomatic Aneurysm
130
Rupture Without Bleeding Secondary to Endotension 4 Years After Endovascular
131
Repair of an Abdominal Aortic Aneurysm J ENDOVASC THER 2008;15:702–705
132
2. Brewster DC, Jones JE, Chung TK et al. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Ann Surg. 2006;244(3):426–438.
133 134
3. F.L. Moll J.T. Powell, G. Fraedrich et al Management of Abdominal Aortic
135
Aneurysms Clinical Practice Guidelines of the European Society for Vascular
136
Surgery Eur J Vasc Endovasc Surg (2011) 41, S1-S58
137
4. Elliot L. Chaikof Dalman, Mark K. Eskandari et al. The Society for Vascular
138
Surgery practice guidelines on the care of patients with an abdominal aortic
139
aneurysm. J Vasc Surg 2018; 67:2-77.
140
5.
Andrew Brown, Greta K Saggu, Matthew J Bown et al. Type II endoleaks:
141
challenges and solutions. Vascular Health and Risk Management 2016:12 53–63
142
6. John D. Kakisis, Konstantinos G. Moulakakis, Constantine N. Antonopoulos
143
et al. Volume of new-onset thrombus is associated with the development of
144
postimplantation syndrome after endovascular aneurysm repair J Vasc Surg
145
2014;60:1140-5.
146 147
Figure legends:
148
Fig. 1. CT angiography (one month postoperatively) which reveals a type II endoleak (note
149
the patency of three lumbar arteries and inferior mesenteric artery)
150
Fig. 2. CT angiography (four months postoperatively) which reveals rupture of the aortic wall
151
without extravasastion. Please notice that there is no aortic-wall thickening, no air around the
152
graft and no soft tissue greater than 5 mm between psoas and the stent graft, fluid collection.
153
Fig. 3. Digital subtraction angiography revealed a small type II endoleak in delayed phase.