Annals of Vascular Surgery - Brief Reports and Innovations (Mar 2022)
Transgraft endovascular repair of symptomatic type IIIb endoleak following endovascular repair of a thoracoabdominal aortic aneurysm
Abstract
Purpose: To report a case of a symptomatic type IIIb endoleak treated by a transgraft embolization approach. Case description: A 66-year-old Caucasian male with a 5.7 cm type IV thoracoabdominal aneurysm (TAAA), which was previously urgently repaired with a four-vessel physician-modified endovascular graft (PMEG), presented with worsening of back pain. The patient has been deemed a prohibitive surgical risk for any open vascular procedure due to episodes of unstable angina and his poor candidacy for additional coronary revascularization despite multiple previous coronary stents. He was found to have a type IIIb endoleak, which was associated with the left renal fenestration on computed tomography (CT) angiogram. The patient was taken to the operating room and an initial attempt to improve the left renal artery stent apposition was unsuccessful after performing balloon angioplasty plus intravascular ultrasound interrogation. However, a tear underneath the fenestration ring was confirmed by placing a catheter underneath the fenestration ring. Thus, a decision was made to employ a transgraft approach to repair the endoleak and avoid transcaval or translumbar approach. A laser-assisted fenestration through the left iliac limb of the previous endograft was performed to access the aneurysm sac. Of note, there was no room to deploy an aortic cuff without converting the repair into a four-vessel chimney endovascular aortic repair (ChEVAR). A combination of microcoils and Gelfoam® thrombin particulates was carefully placed to the nidus of the leak from the inside of the stent-graft lumen forming a “sandwich” (thrombin behind coils) patch configuration. The patient was free of any symptoms or pertinent vascular findings at the one-year follow-up. A CTA showed a complete resolution of the previous endoleak and associated symptoms, and regression of the aneurysmal sac diameter. Conclusion: Transgraft embolization appears feasible in completely excluding a challenging type IIIb endoleak in patients not amenable to open repair. This method should be considered an alternative to relining the defect with the deployment of additional components (e.g., ChEVAR) or additional aortic stent-grafts, especially in inadequate luminal space and room between bridging stents.
