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A complication of open abdominal aortic aneurysm repair closely resembling a type II endoleak
A complication of open abdominal aortic aneurysm repair closely resembling a type II endoleak Mark D. Wheatcroft, MBChB, Robert J. Lonsdale, MBBS, and Douglas Turner, MBBS, Sheffield, United Kingdom Endoleak is a well-recognized complication of endovascular treatment of abdominal aortic aneurysms. Despite over 40 years of open transabdominal aortic aneurysm surgery, only in the last decade has endoleak as a complication of open surgery been described. Endoleak after conventional open surgery was first described by Chan et al in 2000 and remains a rare complication. We describe the first reported case of type II endoleak (back-bleeding inferior mesenteric artery) after open repair of abdominal aortic aneurysm, and its successful management by endovascular coil embolization. ( J Vasc Surg 2011;54:1798-1800.)
Endoleak is defined as blood flow outside the lumen of an endoluminal graft but within the adjacent aneurysm sac or adjacent vascular segment treated by the graft and has become a well-recognized complication of endovascular (EVAR) treatment of abdominal aortic aneurysms (AAA).1 Despite over 40 years of open transabdominal aortic aneurysm surgery (endoaneurysmorrhaphy),2 only in the last decade has endoleak as a complication of open surgery been described. Endoleak after conventional open surgery was first described by Chan et al in 2000 and remains a rare complication.3 We describe a case of type IIa endoleak from the inferior mesenteric artery (IMA) after open repair of AAA, successfully treated by endovascular coil embolization. CASE REPORT An 85-year-old male was referred as an emergency with abdominal pain and a pulsatile abdominal mass having undergone an open juxtarenal AAA repair 4 years earlier. On arrival in the emergency department, he was conscious and undistressed. His pulse was 70, blood pressure 220/70, and he was apyrexial with an O2 saturation of 100% on air. He gave a 24-hour history of new left-sided abdominal pain with no other associated symptoms. It was noted that he received dialysis for end-stage kidney disease and had suffered a perioperative myocardial infarction (MI) during his previous AAA repair. Examination revealed a midline laparotomy scar and a large expansile pulsatile mass in his mid and lower left abdomen that was mildly tender. He had a full compliment of peripheral pulses. Abdominal computed tomography (CT) showed a 10-cm infrarenal aortic aneurysm containing a large amount of thrombus. From the Sheffield Vascular Institute, Northern General Hospital. Competition of interest: none. Reprint requests: Mark D. Wheatcroft, MD, Sheffield Vascular Institute, Northern General Hospital, Herries Road, Sheffield, South Yorkshire, UK S5 7AU (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2011 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.06.026
1798
Following IV contrast, a 3.5-cm diameter area of contrast could be seen within the thrombus, separate to the aortic graft lumen, and which was in continuity with the IMA (Fig 1, a and b). There was no evidence of a rupture or leak. Back-bleeding from a patent IMA, resembling a type II endoleak was therefore diagnosed. The patient was treated with analgesia and antihypertensives, and 1 day later, a selective superior mesenteric artery catheterization was performed via a right common femoral artery puncture. A microcatheter was then advanced along the left colic artery and into the IMA trunk. An angiogram confirmed that this was the source of the endoleak and the vessel was successfully embolized using six Interlock fibered IDC coils (Boston Scientific), (Fig 2). The patient was discharged 24 hours later and a follow-up CT scan performed 4 weeks later which showed no endoleak but a small increase in AAA diameter (Fig 1, c and d). A delayed phase CT scan also showed no endoleak. A duplex scan at 4 months failed to detect an endoleak. The patient died of a myocardial infarction 15 months postintervention without further imaging. Myocardial infarction was diagnosed on the basis of chest pain and elevated serum troponin I Ultra of 2.49 ng/L. Neither an abdominal CT scan or post-mortem examination were performed, thus, a further complication of the AAA cannot be categorically excluded. The operation note from 2005 recorded that two lumbar arteries were oversewn and that no IMA was identified. The sac and retroperitoneum were both closed.
DISCUSSION Resnikoff et al reported a 2% rate of late aneurysm sac patency or persistent flow and 0.8% sac rupture on follow-up in a series of aneurysms repaired using a ligation and exclusion technique.4 However, endoleak following conventional “inlay” open aneurysm surgery is rare with only a few reports in the world literature. The first report was by Chan et al, with a series of six cases of type I endoleak (one proximal, five distal anastomotic leaks), which presented between 6 weeks and 18 months after surgery.3 The most delayed presentation in the literature is a type 1 leak presenting as a rupture 12 years after surgery.5 Type II endoleak can be subdivided into those involving a single vessel (type IIa) or multiple vessels (type IIb).6,7 Type IIa endoleak from a patent lumbar artery was described by Yow
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Fig 1. Contrast-enhanced abdominal computed tomography (CT) scan, arterial phase. Preintervention axial section (a) showing a 10-cm abdominal aortic aneurysm (AAA), bright enhancement of graft lumen, and a 3.5-cm enhancing area in the anterior sac representing the endoleak (white arrow). The feeding inferior mesenteric artery (IMA) (white arrow) can be clearly seen on the sagittal reconstruction (b). Follow-up CT scan at 4 weeks postintervention, axial (c) and sagittal reconstruction (d) images demonstrating successful coil embolization of the IMA and associated endoleak (white arrow).
et al in 2004 in a single case 34 days after surgery.8 We believe this is the first reported case of a type II endoleak from the IMA. The causes for type I endoleak after conventional open AAA repair are usually technical and relate to anastomotic disruption due to either a loose suture, suture breakage, or aortic wall failure due to inadequate anchorage or disease progression. The relatively early presentation of most cases is likely a reflection of the technical nature of the fault. Recanalization of vessels that were occluded at the time of the original operation as part of postimplantation syndrome has been suggested as a cause of delayed presentation of type II endoleak following EVAR. There may be a similar explanation for endoleak after open repair. It has been suggested previously that a rigorous search for all nonbleeding lumbar artery orifices be performed routinely.8 This seems excessive given the apparent rarity of type II endoleaks after open surgery. However, where the IMA origin is easily located it may be appropriate to crossstitch it regardless of back bleeding. Endoleak and graft migration are the primary reasons for close radiological follow-up after EVAR, with a
4-year reintervention rate of 20% being reported by the EVAR I trial. Long-term CT follow-up after open AAA repair is not normal practice in United Kingdom institutions despite there being data to support it. The most recent report from Massachusetts using CT and magnetic resonance imaging (MRI) documents a 2% late graft complication rate over a mean follow-up of 87 months.9 The most common late complication is the development of anastomotic pseudoaneurysms. Another recent study described a 0.5% rupture rate in the 4 years following open repair,10 some of which may have been due to type II endoleaks. No long-term follow-up study has identified a case of endoleak after open repair but the detection of other post-AAA repair pathology, and the development of new aneurysms provides reason for radiologic follow-up in long-term survivors.11 Chan et al propose a new classification of endoleak following open surgery that differs from that described by White for endovascular repair.1,3 Their classification of anastomotic disruption as type I endoleak is prone to inaccuracy and may lead to confusion. However, backbleeding lumbar and IMA after open repair bear striking
1800 Wheatcroft et al
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Fig 2. Transfemoral mesenteric angiogram of the left colic artery and its communication with the inferior mesenteric artery (IMA) (a). Microcatheter being introduced over a guidewire into the IMA via the left colic artery (b). Angiogram demonstrating successful coil embolization of the IMA origin (c).
diagnostic and therapeutic similarities to those seen after EVAR, and we therefore suggest that they can be referred to as type II endoleaks. They also suggest considering endoleak as a complication of open aneurysm surgery up to 18 months after surgery. The case described by Matsushita and the case presented here indicate that the diagnosis of endoleak should be considered in symptomatic patients irrespective of time after surgery. REFERENCES 1. White GH, Yu W, May J, Chaufour X, Stephen MS. Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, incidence, diagnosis, and management. J Endovasc Surg 1997;4:152-68. 2. Creech O Jr. Endoaneurysmorrhaphy and treatment of aortic aneurysm. Ann Surg 1966;164:935-46. 3. Chan CL, Ray SA, Taylor PR, Fraser SC, Giddings AE. Endoleaks following conventional open abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2000;19:313-7. 4. Resnikoff M, Darling RC III, Chang BB, Lloyd WE, Paty PS, Leather RP, et al. Fate of the excluded abdominal aortic aneurysm sac: longterm follow-up of 831 patients. J Vasc Surg 1996;24:851-5.
5. Matsushita M, Ikezawa T, Banno H. Type 1 endo-leak phenomenon causing rupture of the replaced aneurysm sac 12 years after open repair of abdominal aortic aneurysm. Ann Vasc Dis 2008;1:118-20. 6. White GH, May J, Waugh RC, Yu W. Type I and type II endoleaks: a more useful classification for reporting results of endoluminal AAA repair. J Endovasc Surg 1998;5:189-91. 7. Baum RA, Stavropoulos SW, Fairman RM, Carpenter JP. Endoleaks after endovascular repair of abdominal aortic aneurysms. J Vasc Intervent Radiol 2003;14:1111-7. 8. Yow H, McCleary AJ. Late lumbar hemorrhage after open repair of abdominal aortic aneurysm: computed tomographic appearance resembling type II endoleak. J Vasc Surg 2004;40:1037-9. 9. Conrad MF, Crawford RS, Pedraza JD, Brewster DC, Lamuraglia GM, Corey M, et al. Long-term durability of open abdominal aortic aneurysm repair. J Vasc Surg 2007;46:669-75. 10. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008;358:464-74. 11. Kalman PG, Rappaport DC, Merchant N, Clarke K, Johnston KW. The value of late computed tomographic scanning in identification of vascular abnormalities after abdominal aortic aneurysm repair. J Vasc Surg 1999;29:442-50.
Submitted May 4, 2011; accepted Jun 7, 2011.
Endoleak is defined as blood flow outside the lumen of an endoluminal graft but within the adjacent aneurysm sac or adjacent vascular segment treated by the graft and has become a well-recognized complication of endovascular (EVAR) treatment of abdominal aortic aneurysms (AAA).1 Despite over 40 years of open transabdominal aortic aneurysm surgery (endoaneurysmorrhaphy),2 only in the last decade has endoleak as a complication of open surgery been described. Endoleak after conventional open surgery was first described by Chan et al in 2000 and remains a rare complication.3 We describe a case of type IIa endoleak from the inferior mesenteric artery (IMA) after open repair of AAA, successfully treated by endovascular coil embolization. CASE REPORT An 85-year-old male was referred as an emergency with abdominal pain and a pulsatile abdominal mass having undergone an open juxtarenal AAA repair 4 years earlier. On arrival in the emergency department, he was conscious and undistressed. His pulse was 70, blood pressure 220/70, and he was apyrexial with an O2 saturation of 100% on air. He gave a 24-hour history of new left-sided abdominal pain with no other associated symptoms. It was noted that he received dialysis for end-stage kidney disease and had suffered a perioperative myocardial infarction (MI) during his previous AAA repair. Examination revealed a midline laparotomy scar and a large expansile pulsatile mass in his mid and lower left abdomen that was mildly tender. He had a full compliment of peripheral pulses. Abdominal computed tomography (CT) showed a 10-cm infrarenal aortic aneurysm containing a large amount of thrombus. From the Sheffield Vascular Institute, Northern General Hospital. Competition of interest: none. Reprint requests: Mark D. Wheatcroft, MD, Sheffield Vascular Institute, Northern General Hospital, Herries Road, Sheffield, South Yorkshire, UK S5 7AU (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2011 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.06.026
1798
Following IV contrast, a 3.5-cm diameter area of contrast could be seen within the thrombus, separate to the aortic graft lumen, and which was in continuity with the IMA (Fig 1, a and b). There was no evidence of a rupture or leak. Back-bleeding from a patent IMA, resembling a type II endoleak was therefore diagnosed. The patient was treated with analgesia and antihypertensives, and 1 day later, a selective superior mesenteric artery catheterization was performed via a right common femoral artery puncture. A microcatheter was then advanced along the left colic artery and into the IMA trunk. An angiogram confirmed that this was the source of the endoleak and the vessel was successfully embolized using six Interlock fibered IDC coils (Boston Scientific), (Fig 2). The patient was discharged 24 hours later and a follow-up CT scan performed 4 weeks later which showed no endoleak but a small increase in AAA diameter (Fig 1, c and d). A delayed phase CT scan also showed no endoleak. A duplex scan at 4 months failed to detect an endoleak. The patient died of a myocardial infarction 15 months postintervention without further imaging. Myocardial infarction was diagnosed on the basis of chest pain and elevated serum troponin I Ultra of 2.49 ng/L. Neither an abdominal CT scan or post-mortem examination were performed, thus, a further complication of the AAA cannot be categorically excluded. The operation note from 2005 recorded that two lumbar arteries were oversewn and that no IMA was identified. The sac and retroperitoneum were both closed.
DISCUSSION Resnikoff et al reported a 2% rate of late aneurysm sac patency or persistent flow and 0.8% sac rupture on follow-up in a series of aneurysms repaired using a ligation and exclusion technique.4 However, endoleak following conventional “inlay” open aneurysm surgery is rare with only a few reports in the world literature. The first report was by Chan et al, with a series of six cases of type I endoleak (one proximal, five distal anastomotic leaks), which presented between 6 weeks and 18 months after surgery.3 The most delayed presentation in the literature is a type 1 leak presenting as a rupture 12 years after surgery.5 Type II endoleak can be subdivided into those involving a single vessel (type IIa) or multiple vessels (type IIb).6,7 Type IIa endoleak from a patent lumbar artery was described by Yow
JOURNAL OF VASCULAR SURGERY Volume 54, Number 6
Wheatcroft et al 1799
Fig 1. Contrast-enhanced abdominal computed tomography (CT) scan, arterial phase. Preintervention axial section (a) showing a 10-cm abdominal aortic aneurysm (AAA), bright enhancement of graft lumen, and a 3.5-cm enhancing area in the anterior sac representing the endoleak (white arrow). The feeding inferior mesenteric artery (IMA) (white arrow) can be clearly seen on the sagittal reconstruction (b). Follow-up CT scan at 4 weeks postintervention, axial (c) and sagittal reconstruction (d) images demonstrating successful coil embolization of the IMA and associated endoleak (white arrow).
et al in 2004 in a single case 34 days after surgery.8 We believe this is the first reported case of a type II endoleak from the IMA. The causes for type I endoleak after conventional open AAA repair are usually technical and relate to anastomotic disruption due to either a loose suture, suture breakage, or aortic wall failure due to inadequate anchorage or disease progression. The relatively early presentation of most cases is likely a reflection of the technical nature of the fault. Recanalization of vessels that were occluded at the time of the original operation as part of postimplantation syndrome has been suggested as a cause of delayed presentation of type II endoleak following EVAR. There may be a similar explanation for endoleak after open repair. It has been suggested previously that a rigorous search for all nonbleeding lumbar artery orifices be performed routinely.8 This seems excessive given the apparent rarity of type II endoleaks after open surgery. However, where the IMA origin is easily located it may be appropriate to crossstitch it regardless of back bleeding. Endoleak and graft migration are the primary reasons for close radiological follow-up after EVAR, with a
4-year reintervention rate of 20% being reported by the EVAR I trial. Long-term CT follow-up after open AAA repair is not normal practice in United Kingdom institutions despite there being data to support it. The most recent report from Massachusetts using CT and magnetic resonance imaging (MRI) documents a 2% late graft complication rate over a mean follow-up of 87 months.9 The most common late complication is the development of anastomotic pseudoaneurysms. Another recent study described a 0.5% rupture rate in the 4 years following open repair,10 some of which may have been due to type II endoleaks. No long-term follow-up study has identified a case of endoleak after open repair but the detection of other post-AAA repair pathology, and the development of new aneurysms provides reason for radiologic follow-up in long-term survivors.11 Chan et al propose a new classification of endoleak following open surgery that differs from that described by White for endovascular repair.1,3 Their classification of anastomotic disruption as type I endoleak is prone to inaccuracy and may lead to confusion. However, backbleeding lumbar and IMA after open repair bear striking
1800 Wheatcroft et al
JOURNAL OF VASCULAR SURGERY December 2011
Fig 2. Transfemoral mesenteric angiogram of the left colic artery and its communication with the inferior mesenteric artery (IMA) (a). Microcatheter being introduced over a guidewire into the IMA via the left colic artery (b). Angiogram demonstrating successful coil embolization of the IMA origin (c).
diagnostic and therapeutic similarities to those seen after EVAR, and we therefore suggest that they can be referred to as type II endoleaks. They also suggest considering endoleak as a complication of open aneurysm surgery up to 18 months after surgery. The case described by Matsushita and the case presented here indicate that the diagnosis of endoleak should be considered in symptomatic patients irrespective of time after surgery. REFERENCES 1. White GH, Yu W, May J, Chaufour X, Stephen MS. Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, incidence, diagnosis, and management. J Endovasc Surg 1997;4:152-68. 2. Creech O Jr. Endoaneurysmorrhaphy and treatment of aortic aneurysm. Ann Surg 1966;164:935-46. 3. Chan CL, Ray SA, Taylor PR, Fraser SC, Giddings AE. Endoleaks following conventional open abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2000;19:313-7. 4. Resnikoff M, Darling RC III, Chang BB, Lloyd WE, Paty PS, Leather RP, et al. Fate of the excluded abdominal aortic aneurysm sac: longterm follow-up of 831 patients. J Vasc Surg 1996;24:851-5.
5. Matsushita M, Ikezawa T, Banno H. Type 1 endo-leak phenomenon causing rupture of the replaced aneurysm sac 12 years after open repair of abdominal aortic aneurysm. Ann Vasc Dis 2008;1:118-20. 6. White GH, May J, Waugh RC, Yu W. Type I and type II endoleaks: a more useful classification for reporting results of endoluminal AAA repair. J Endovasc Surg 1998;5:189-91. 7. Baum RA, Stavropoulos SW, Fairman RM, Carpenter JP. Endoleaks after endovascular repair of abdominal aortic aneurysms. J Vasc Intervent Radiol 2003;14:1111-7. 8. Yow H, McCleary AJ. Late lumbar hemorrhage after open repair of abdominal aortic aneurysm: computed tomographic appearance resembling type II endoleak. J Vasc Surg 2004;40:1037-9. 9. Conrad MF, Crawford RS, Pedraza JD, Brewster DC, Lamuraglia GM, Corey M, et al. Long-term durability of open abdominal aortic aneurysm repair. J Vasc Surg 2007;46:669-75. 10. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008;358:464-74. 11. Kalman PG, Rappaport DC, Merchant N, Clarke K, Johnston KW. The value of late computed tomographic scanning in identification of vascular abnormalities after abdominal aortic aneurysm repair. J Vasc Surg 1999;29:442-50.
Submitted May 4, 2011; accepted Jun 7, 2011.