Print this pageInfrarenal endograft preservation accomplished by limited open exposure interventions for complex AAA endoleaks
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Martin R. Back, MD, Robert Brumberg, MD, Patrick Stone, MD, Murray Shames, MD, Brad Johnson, MD, Dennis Bandyk, MD.
Univ of South Florida, Tampa, FL, USA.
Background : To describe less invasive operative techniques used to treat recalcitrant endoleaks persisting after endovascular AAA repair and permitting endograft preservation.
Methods : Of 325 patients undergoing endovascular repair of infrarenal aortoiliac aneurysms since 1999, 20 patients (6.1%) required secondary endovascular procedures for proximal migration and/or type I leak (n=4, proximal cuffs) or type II leaks with AAA growth > 5mm (n=16, translumbar aortic sac/branch embolizations). Five patients (1.5%, all men, ages 56-85 yo) experienced persistent endoleak after secondary interventions. To avoid open conversion and facilitate endograft preservation, limited (< 15cm incisions) transabdominal (n=3) or retroperitoneal (n=2) exposures were used for obliteration of recalcitrant endoleaks by suture plication of the pararenal aorta and proximal endograft (n=2 type I leaks) or direct trans-sac ligation of patent aortic branch origins (n=3 type II leaks). Procedures were performed under general anesthetic with aortic sac pressure monitoring and duplex ultrasonography. An extension iliac cuff was concomitantly deployed in one case for inadequate distal endograft fixation.
Results : Operative times were under 90 minutes, blood loss ranged from 250-1500 mL and was greatest for lumbar ligations. Hospital stays ranged from 3 to 6 days and no peri- operative (<30 days) mortalities or major complications occurred. During follow-up ranging from 4 to 46 months, all endoleaks remained obliterated by serial CT imaging, all aneurysms followed more than 1 year (n=3) had sac size diminish by more than 1cm, and no other endograft-related adverse event occurred. One patient followed for 46 months died of cardiac causes, while the remaining 4 patients remain alive. In our overall experience (mean follow-up 30 months), no late open conversions have been necessary, a single late AAA rupture has occurred (0.3%) and cumulative aneurysm-related mortality remains less than 2%.
Conclusions : Less-invasive operative techniques can be effectively used to obliterate recalcitrant type I and II endoleaks after failed secondary endovascular interventions. Endograft preservation and favorable late aneurysm behaviour have been achieved with low procedural risk.