Nicholas J Swerdlow1, John C McCallum1, Patric Liang1, Chun Li1, Thomas F X O'Donnell1, Rens R B Varkevisser2, Marc L Schermerhorn3. 1. Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. 2. Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands. 3. Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
Abstract
OBJECTIVE: The Society for Vascular Surgery reporting standards for endovascular aneurysm repair (EVAR) consider the presence of a type I or type III endoleak a technical failure. However, the nature and implications of these endoleaks in fenestrated EVAR (FEVAR) are not well understood. METHODS: We performed a single-center retrospective review of 53 patients who underwent FEVAR with the Zenith Fenestrated AAA Endovascular Graft (Cook Medical, Bloomington, Ind) from 2013 to 2018. We excluded one patient without contrast-enhanced postoperative imaging who was lost to follow-up after discharge. Small, slow, type I and type III endoleaks on completion angiography were routinely observed. We identified patients with completion type I or type III endoleaks by angiography review and characterized endoleak type, location, and rate of resolution on initial postoperative imaging. RESULTS: Fifty-two patients were included; mean age was 75 ± 8 years, 75% were male, and 91% were white. Of 146 visceral vessels (100 renal arteries and 46 superior mesenteric arteries), 145 (99%) were preserved with 103 fenestrations and 43 scallops; 102 (70%) target vessels were stented. After implantation of all device components, 31 patients (60%) had evidence of type I or type III endoleak. Twelve patients (39%) underwent further intervention at the index procedure, and three endoleaks resolved completely. Twenty-eight patients (54%) had a type I or type III endoleak on completion angiography. There were no differences between patients with and without completion endoleaks in baseline demographics, graft design, neck anatomy, or proportion of cases performed within the instructions for use of the device. Perioperative mortality was 1.9%. On initial postoperative imaging, 27 of 28 (96%) endoleaks resolved spontaneously. One small, persistent type IA or type III endoleak was identified on postoperative day 27 and was observed. This endoleak had resolved completely on computed tomography angiography 6 months postoperatively. In patients without a completion endoleak, one type IA endoleak secondary to graft infolding was discovered on postoperative imaging and was successfully treated with placement of endoanchors and Palmaz stent. Median follow-up was 269 days. No additional type I or type III endoleaks were identified in any patient for the duration of follow-up. CONCLUSIONS: Whereas completion type I and type III endoleaks are common after FEVAR with the ZFEN device, nearly all of these endoleaks resolve spontaneously by the initial postoperative imaging. These results suggest that select completion endoleaks after FEVAR with the ZFEN device do not require intervention at the index procedure.
OBJECTIVE: The Society for Vascular Surgery reporting standards for endovascular aneurysm repair (EVAR) consider the presence of a type I or type III endoleak a technical failure. However, the nature and implications of these endoleaks in fenestrated EVAR (FEVAR) are not well understood. METHODS: We performed a single-center retrospective review of 53 patients who underwent FEVAR with the Zenith Fenestrated AAA Endovascular Graft (Cook Medical, Bloomington, Ind) from 2013 to 2018. We excluded one patient without contrast-enhanced postoperative imaging who was lost to follow-up after discharge. Small, slow, type I and type III endoleaks on completion angiography were routinely observed. We identified patients with completion type I or type III endoleaks by angiography review and characterized endoleak type, location, and rate of resolution on initial postoperative imaging. RESULTS: Fifty-two patients were included; mean age was 75 ± 8 years, 75% were male, and 91% were white. Of 146 visceral vessels (100 renal arteries and 46 superior mesenteric arteries), 145 (99%) were preserved with 103 fenestrations and 43 scallops; 102 (70%) target vessels were stented. After implantation of all device components, 31 patients (60%) had evidence of type I or type III endoleak. Twelve patients (39%) underwent further intervention at the index procedure, and three endoleaks resolved completely. Twenty-eight patients (54%) had a type I or type III endoleak on completion angiography. There were no differences between patients with and without completion endoleaks in baseline demographics, graft design, neck anatomy, or proportion of cases performed within the instructions for use of the device. Perioperative mortality was 1.9%. On initial postoperative imaging, 27 of 28 (96%) endoleaks resolved spontaneously. One small, persistent type IA or type III endoleak was identified on postoperative day 27 and was observed. This endoleak had resolved completely on computed tomography angiography 6 months postoperatively. In patients without a completion endoleak, one type IA endoleak secondary to graft infolding was discovered on postoperative imaging and was successfully treated with placement of endoanchors and Palmaz stent. Median follow-up was 269 days. No additional type I or type III endoleaks were identified in any patient for the duration of follow-up. CONCLUSIONS: Whereas completion type I and type III endoleaks are common after FEVAR with the ZFEN device, nearly all of these endoleaks resolve spontaneously by the initial postoperative imaging. These results suggest that select completion endoleaks after FEVAR with the ZFEN device do not require intervention at the index procedure.
Authors: Wieland H Sommer; Christoph R Becker; Mareike Haack; Geoffrey D Rubin; Rolf Weidenhagen; Florian Schwarz; Konstantin Nikolaou; Maximilian F Reiser; Thorsten R Johnson; Dirk A Clevert Journal: Radiology Date: 2012-06 Impact factor: 11.105
Authors: Thomas F X O'Donnell; Michael R Corey; Sarah E Deery; Gregory Tsougranis; Rohit Maruthi; W Darrin Clouse; Richard P Cambria; Mark F Conrad Journal: J Vasc Surg Date: 2018-01 Impact factor: 4.268
Authors: Alistair M Millen; Khabab Osman; George A Antoniou; Richard G McWilliams; John A Brennan; Robert K Fisher Journal: J Vasc Surg Date: 2015-02-02 Impact factor: 4.268
Authors: F Bastos Gonçalves; H J M Verhagen; K Vasanthananthan; H J A Zandvoort; F L Moll; J A van Herwaarden Journal: Eur J Vasc Endovasc Surg Date: 2014-02-26 Impact factor: 7.069
Authors: S Keisin Wang; Ashley R Gutwein; Alok K Gupta; Gary W Lemmon; Alan P Sawchuk; Raghu L Motaganahalli; Michael P Murphy; Andres Fajardo Journal: J Vasc Surg Date: 2018-02-01 Impact factor: 4.268
Authors: Gustavo S Oderich; Roy K Greenberg; Mark Farber; Sean Lyden; Luis Sanchez; Ron Fairman; Feiyi Jia; Priya Bharadwaj Journal: J Vasc Surg Date: 2014-09-05 Impact factor: 4.268
Authors: Andrew S Levey; Lesley A Stevens; Christopher H Schmid; Yaping Lucy Zhang; Alejandro F Castro; Harold I Feldman; John W Kusek; Paul Eggers; Frederick Van Lente; Tom Greene; Josef Coresh Journal: Ann Intern Med Date: 2009-05-05 Impact factor: 25.391