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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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Part II - Final strategy
  1. After pneumoperitoneum induction, the flaccid part was opened and splenic, left gastric and hepatic arteries were identified and carefully isolated.
  2. The vessels were temporary clamped and green indocyanin was injected to exclude visceral ischemia.
  3. So, finally, the celiac  trunk was closed with a clip at its origin from the aorta.

Robotic celiac trunk ligature

After pneumoperitoneum induction, the flaccid part was opened and splenic
  1. Type II endoleak (A);
  2. Celiac branches temporary robotic clamping (B);
  3. Check with indocyanin green injection (C);
  4. Type II endoleak complete resolution after celiac trunk ligature (D). 
Robotic celiac trunk ligature

CT-scan follow-up

  1. Complete type II endoleak resolution
  2. Absence of visceral ischemia
  3. No spinal cord ischemia
Complete type II endoleak resolution

Conclusions

  • Type II endoleak is very frequent after endovascular abdominal aortic aneurysm repair, but its incidence is underinvestigated after endovascular exclusion of a thoraco-abdominal aneurysm.
  • Usually, it is followed up and treated only in cases of aneurysmal sac enlargement.
  • The celiac trunk robotic ligature is minimal invasive and can offer excellent results.
  • The current literature reports some cases of inferior mesenteric artery or lumbar arteries robotic ligature, but celiac trunk robotic ligature to treat type II endoleak has never been reported to date.
     

Total robotic ligation of inferior mesenteric artery for type II endoleak after endovascular aneurysm repair.
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Morelli L, Guadagni S, Di Franco G, Palmeri M, Furbetta N, Gianardi D, Bianchini M, Moglia A, Di Candio G, Ferrari M, Berchiolli R.
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Indocyanine green colonic perfusion demonstration following robotic da Vinci X inferior mesenteric artery ligation for the treatment of type II endoleak.
Lambert J, Al Majid S, Salaman R, Gavan D, Sheikh A, Gill M.
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doi: 10.1002/rcs.2407. Epub 2022 Apr 23.