Endotension after Abdominal Aortic Aneurysm Endovascular Repair in Cirrhotic Patients

Accepted Manuscript Endotension after Abdominal Aortic Aneurysm Endovascular Repair in Cirrhotic Patients Tommaso Cambiaghi, Domenico Baccellieri, Daniele Mascia, Germano Melissano, Roberto Chiesa, Andrea Kahlberg PII:

S0890-5096(17)30861-0

DOI:

10.1016/j.avsg.2017.06.148

Reference:

AVSG 3483

To appear in:

Annals of Vascular Surgery

Received Date: 2 June 2017 Revised Date:

26 June 2017

Accepted Date: 27 June 2017

Please cite this article as: Cambiaghi T, Baccellieri D, Mascia D, Melissano G, Chiesa R, Kahlberg A, Endotension after Abdominal Aortic Aneurysm Endovascular Repair in Cirrhotic Patients, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2017.06.148. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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.

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ENDOTENSION AFTER ABDOMINAL AORTIC ANEURYSM ENDOVASCULAR REPAIR IN

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CIRRHOTIC PATIENTS

Authors

Tommaso Cambiaghi, Domenico Baccellieri, Daniele Mascia, Germano Melissano, Roberto Chiesa,

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Andrea Kahlberg

Department of Vascular Surgery

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From

Vita-Salute University, San Raffaele Scientific Institute

Corresponding author:

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Tommaso Cambiaghi, M.D.

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Via Olgettina 60, 20132, Milano, Italy

Department of Vascular Surgery

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Vita-Salute University School of Medicine, San Raffaele Scientific Institute Via Olgettina 60, 20132, Milano, Italy Phone: +39.02.2643.7130, Fax: +39.02.2643.7148 E-mail: [email protected]

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ABSTRACT

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Purpose: Endotension can present a real challenge for the long-term success of EVAR.

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Sometimes it can be associated to liver dysfunction and consequent plasmatic alterations as in the

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two cases reported here.

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Case report: Significant and progressive AAA sac enlargement, without radiological signs of

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endoleak, was observed in two patients during a 3-year follow-up after EVAR. The first was a 70-

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year-old man affected by viral liver cirrhosis; the second was a 71-year-old man with cirrhosis due

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to alcoholic liver disease. Both patients underwent successful conversion to open AAA repair; intraoperative findings confirmed the diagnosis of endotension.

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Conclusions: Cirrhosis-induced plasmatic alterations may impact long-term efficacy of

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EVAR and should be considered when weighing endovascular treatment against open AAA repair

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in these high-risk patients. Surgical conversion is feasible despite the high procedural risk

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associated with liver disease.

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INTRODUCTION

18 Endovascular aortic repair (EVAR) is considered the technique of choice for the management

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of infrarenal abdominal aortic aneurysms (AAA) in high-risk patients,1 including cirrhotics.

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However, specific complications of EVAR have been reported, including coagulopathy. Moreover,

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the long-term efficacy of EVAR in patients with chronic liver dysfunction has never been

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specifically addressed.2 We report two cases in which late open conversion was needed due to sac

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endotension following EVAR of infrarenal AAA, with no evidence of active reperfusion of the

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aneurysmal sac (type I, II or III endoleak).

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CASE REPORTS

28 Patient 1

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A 70-year-old man was diagnosed with infrarenal AAA in 2010 with a maximum diameter of

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48 mm. Relevant comorbidities included cirrhosis secondary to hepatitis B virus chronic infection

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(Child-Pugh score A) causing chronic thrombocytopenia (77x109/L at admission). The patient

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underwent EVAR with a bifurcated E-vita abdominal stent-graft (JOTEC, Hechingen, Germany).

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Six months later, he was submitted to laparoscopic ligation of the inferior mesenteric artery, and

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concurrent right iliac stent-graft extension due to a suspected combined type Ib and type II endoleak.

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After 40 months from initial EVAR, the patient was admitted to our department due to rapid sac

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enlargement (more than 10 mm in 12 months), reaching 73-mm in maximum diameter, without any

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sign of active endoleak at Duplex scan and at contrast-enhanced computed tomography (CT) scan

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(Fig. 1). Pre-operative platelet count was 71x109/L, haematocrit 36%, prothrombin time (PT) 18.7

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sec, international normalized ratio (INR) 1.58, activated partial thromboplastin time (APTT) 34.2

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sec. Conversion to open AAA repair was performed via midline laparotomy and transperitoneal

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approach. After aneurysm exposure, a needle probe connected to a pressure transducer revealed a

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non-pulsatile sac pressure similar to mean systemic blood pressure. After sac incision no active

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bleeding from aneurysm necks, or back-bleeding from patent collaterals was observed. Diffuse

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“oozing-like” bleeding through the stent-graft fabric was evident. No discontinuity in the graft

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material was found. The stent-graft was sectioned close to the proximal neck and distally to the

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bifurcation, according to our previously described technique.3 A 22-mm silver-coated Dacron tube

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graft (Silver Graft, B Braun Melsungen AG, Melsungen, Germany) was anastomosed end-to-end to

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the aortic wall and the residual stent-graft with interposition of Teflon felt strips both in the

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proximal and distal anastomosis (Fig. 2). Gelatine-resorcinol-formaldehyde glue (Cardial,

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Technopole, Sainte-Etienne, France) was applied on the prosthesis after completion of the

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anastomoses.

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Post-operative course was uneventful. Copious amounts of translucent yellow fluid were

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initially collected by the abdominal drain, with progressive reduction during the next 4 days

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following administration of diuretics and octreotide. Abdominal ultrasound, showing no periaortic

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fluid collection, was performed before drain removal. The patient was discharged on postoperative

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day 11 to a rehabilitation centre and is alive and well at 6-month follow-up.

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Patient 2

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A 71-year-old man was diagnosed in 2011 with infrarenal AAA with a maximum diameter of

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50 mm. This patient suffered from cirrhosis secondary to alcoholic liver disease (Child-Pugh score

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A) and associated thrombocytopenia (97x109/L at admission). He underwent EVAR with a

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bifurcated Treovance abdominal stent-graft (Bolton Medical, Barcelona, Spain). Six months later, a

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scheduled CT scan showed AAA maximum diameter increase of 14 mm, with a supposed type II

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endoleak supplied by the inferior mesenteric artery and two ilio-lumbar arteries, treated with

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embolization of Gianturco coils (Boston Scientific Corporation; Natick, Mass) and Glubran glue

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(GEM Srl, Viareggio, Italy) mixed with Lipiodol (Guerbet, RoissyCdGCedex, France).

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He was then re-admitted to our department 32 months after initial EVAR, with follow-up CT

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scans showing a progressive further increase in sac diameter, reaching at the time 78 mm, but no

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evidence of type I or residual type II endoleak (Fig. 1). Pre-operative platelet count was 70x109/L,

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haematocrit 37%, PT 17.3 sec, INR 1.43, APTT 31.7 sec. Open conversion was performed using the same surgical approach described for Patient 1,

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using a 22-mm Dacron graft (Hemashield Platinum; MAQUET Holding B.V. & Co. KG, Rastatt,

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Germany) for aortic reconstruction (Fig. 2). Aneurysmal sac pressure before clamping was

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comparable to mean systemic pressure. At sac opening no active bleeding from necks or collaterals

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was detectable, and diffuse oozing through the stent-graft fabric was noted as in Patient 1.

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Post-operative course was uneventful. Surgical drains initially collected high amounts (about

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400 ml/day) of translucent yellow fluid, self-limiting within the following 4 days. The patient was

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discharged on postoperative day 7 to a rehabilitation centre and is alive and well at 6-month follow-

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up.

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DISCUSSION

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Cirrhosis is a fibrodegenerative hepatic disorder leading to loss of liver function. The defects

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caused by this condition include thrombocytopenia due to secondary splenic sequestration, and

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decreased levels of albumin and coagulation factors due to primary synthesis dysfunction.

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Since abdominal surgery, including AAA open repair, has been considered at high risk in

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cirrhotic patients1, some authors have advocated EVAR as the first choice of treatment. However,

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thrombocytopenia and coagulation disorders may be theoretically responsible for alterations in the

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aneurysmal thrombosis process, even in case of correct aneurysm exclusion and absence of

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detectable endoleak. Accordingly, excessive anticoagulation therapy with warfarin following

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EVAR was previously reported to be responsible for endotension and aneurysm sac enlargement.4

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Evidences in the literature about the possible effects of coagulopathy and cirrhosis-induced

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plasmatic alterations after EVAR are scant, and this should raise a word of caution with the

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endovascular management and follow-up of these patients. In our experience, both patients presented a so-called type V endoleak, namely evidence of

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aneurysm sac enlargement with no detectable endoleak. Type V endoleak may be referred also as

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endotension, especially when persistent or recurrent pressurization of a stent-grafted aneurysm sac

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is proven. According to the classification proposed by the New York International Consensus

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Conference in 2000, both our patients presented a type B endotension, i.e. following previous

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successful sealing of an endoleak.5 These findings may suggest that treatment of an endoleak in

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cirrhotics could be apparently successful, but finally resulting at risk for continuing or recurrent sac

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pressurization.

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Treatment strategies of endotension are different. Open surgical conversion was reported as

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the treatment choice in 8 cases of endotension developed after EVAR with the first-generation high-

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permeability Gore Excluder stent-graft,6 resulting in 100% 30-day survival. Similarly, open

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conversion was successful in the two cases reported herein, even if associated with liver cirrhosis.

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These results are consistent with our previously reported experience with AAA open repair in

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cirrhotics, showing that relatively compensated cirrhotic patients can be operated with acceptable

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perioperative morbidity.7

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Alternative reported treatments of type V endoleak or endotension include endovascular

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relining with graft-in-graft repair, laparoscopic aortic collateral clipping and sac fenestration, open

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aneurysm sac fenestration associated with proximal neck banding, intra-sac injections of pro-

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thrombotic agents, and percutaneous translumbar sac puncture and aspiration. Even if results

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reported might be somewhat encouraging, data are insufficient to draw any conclusion about the

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effectiveness of these alternative techniques.

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In conclusion, the risk of late aneurysm sac enlargement and endotension makes the use of

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EVAR to be carefully evaluated in patients with even mild cirrhosis-induced plasmatic alterations.

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Close monitoring of these patients is mandatory in case of aortic stent-grafting. If progressive or

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rapid sac enlargement are observed, even in absence of detectable endoleak, surgical conversion to

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open AAA repair may be successfully accomplished.

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REFERENCES

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1.Egorova N, Giacovelli JK, Gelijns A, Greco G, Moskowitz A, McKinsey J, et al. Defining high-

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risk patients for endovascular aneurysm repair. J Vasc Surg. 2009 Dec;50(6):1271-9.

125 2. EVAR trial participants. Endovascular aneurysm repair and outcome in patients unfit for open

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repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial. Lancet. 2005;

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365: 2187–92

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3. Marone EM, Mascia D, Coppi G, Tshomba Y, Bertoglio L, Kahlberg A, et al. Delayed open

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conversion after endovascular abdominal aortic aneurysm: device-specific surgical approach. Eur J

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Vasc Endovasc Surg. 2013 May;45(5):457-64.

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4. Iyer VS, Mackenzie KS, Corriveau MM, Steinmetz OK. Reversible endotension associated with

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excessive warfarin anticoagulation. J Vasc Surg. 2007 Mar;45(3):600-2.

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5. Veith FJ, Baum RA, Ohki T, Amor M, Adiseshiah M, Blankensteijn JD, et al. Nature and

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significance of endoleaks and endotension: summary of opinions expressed at an international

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conference. J VascSurg. 2002 May;35(5):1029-35.

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6. Kong LS, MacMillan D, Kasirajan K, Milner R, Dodson TF, Salam AA, et al. Secondary

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conversion of the Gore Excluder to operative abdominal aortic aneurysm repair. J VascSurg. 2005

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Oct;42(4):631-8.

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7. Marrocco-Trischitta MM, Kahlberg A, Astore D, Tshiombo G, Mascia D, Chiesa R. Outcome in

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cirrhotic patients after elective surgical repair of infrarenal aortic aneurysm. J Vasc Surg. 2011

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Apr;53(4):906-11.

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FIGURE LEGENDS

150 Figure 1. Progressive sac enlargement following EVAR in two patients, documented by

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subsequent late-phase contrast enhanced CT scans. In Patient 1 (upper line), no endoleak is visible

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in both scans. In Patient 2 (lower line), a type II endoleak is evident at 6-month scan (arrow), but

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disappears after embolization at subsequent scans.

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Figure 2. Intraoperative technical detail of proximal (A, Patient 2) and distal (B, Patient 1) graft-to-endograft anastomosis, reinforced with Teflon felt strips (arrows).

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