Aorta
TAA

Management of a type II endoleak after thoraco-abdominal aneurysm endovascular exclusion

A 73-year-old man with multiple cardiovascular risk factors presented with acute thoraco-abdominal pain and was found to have a large thoraco-abdominal aneurysm associated with bilateral iliac aneurysms. 

To limit the risk of spinal cord ischemia, a staged endovascular strategy was planned, combining TEVAR, a branched endograft with visceral vessel stenting, and bilateral iliac branch repair. 

Despite the complexity of the procedure and embolisation of the celiac trunk, follow-up imaging at 6 months revealed a persistent type II endoleak with aneurysm sac enlargement, raising the question of optimal secondary management.

Mafalda Massara
Mafalda Massara
GOM Bianchi-Melacrino-Morelli, Italy
Antonino Alberti
Antonino Alberti
GOM Bianchi-Melacrino-Morelli, Italy
User
Pietro Volpe
GOM Bianchi-Melacrino-Morelli, Italy
Part I - Case presentation
  • A 73-year-old male patient
  • Anamnesis: heavy smoker, hypertension, diabetes, dyslipidemia and chronic obstructive pulmonary disease
  • Acute chest, abdominal and lumbar pain
  • Urgent CT scan: voluminous thoraco-abdominal  aneurysm and bilateral iliac aneurysm
Urgent CT scan: voluminous thoraco-abdominal aneurysm and bilateral iliac aneurysm
Urgent CT scan: voluminous thoraco-abdominal aneurysm and bilateral iliac aneurysm

Planning

Due to the extension of the disease, to reduce the risk of spinal cord ischemia, we planned a multistage procedure:

  1. TEVAR (thoracic endovascular aortic repair)
  2. Deployment of a T-branch endograft with left renal artery and superior mesenteric artery stenting
  3. Bilateral iliac branch
  4. Stenting of right renal artery and celiac trunk

Technical drawing

Technical drawing: Integrated bifurcation
Integrated bifurcation
Technical drawing: Integrated bifurcation
3 outer-branches and 1 anterograde inner-branch for left renal artery

Step 1: TEVAR

Step 1: TEVAR
Step 1: TEVAR
Step 1: TEVAR

Step 2:  SMA and LRA stenting

(30 days after step 1)

STEP 2: SMA and LRA stenting

Step 3: bilateral iliac branch

(45 days after step 2)

STEP 3: Bilateral Iliac Branch
STEP 3: Bilateral Iliac Branch, Right and left illiac bifurcation
Right and left illiac bifurcation
STEP 3: Bilateral Iliac Branch
Bilateral iliac branch
STEP 3: Bilateral Iliac Branch

Step 4:

(30 days after step 3)

  • RRA stenting
  • Celiac trunk
    Cannulation
    Failure

↓

  • Celiac trunk
    Branch
    Embolisation
Right renal artery
Right renal artery
Celiac trunk branch embolization
Celiac trunk branch embolisation

Follow-up

At CT scan control, 6 months after operation, the patient had a type-2 endoleak with enlargement of the aneurysmal sac.

 

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