Successful Repair of a Type 2 Endoleak with Coiling of Inferior Mesenteric Artery

ABSTRACT: Background. One of the most common complications of endovascular aneurysm repair (EVAR) is type 2 endoleak. We describe a patient who presented with a recurrent endoleak despite initial intervention and was successfully treated with coil embolization of the inferior mesenteric artery (IMA).

Case Report. A 63-year-old Caucasian male was found to have a 7.5 cm abdominal aortic aneurysm (AAA) during a routine ultrasound of the kidneys. The patient successfully underwent EVAR with exclusion of the aneurysm sac. A computed tomographic (CT) scan was performed 30 days after the procedure, and showed presence of a large type 1a endoleak with slight enlargement of the sac. The endoleak was successfully repaired with 2 extension cuffs which resulted in resolution of the endoleak. A few months later, another CT scan was performed that showed a type 2 endoleak without enlargement of the sac; however, there was no reduction in the size of the sac. Multiplanar reconstruction was used and a small branch connecting the superior mesenteric artery (SMA) to the inferior mesenteric artery (IMA) through the marginal artery was found. A selective angiogram of the SMA was performed that showed filling of the aneurysm sac. A microcatheter was advanced through the SMA and marginal artery into the IMA. The IMA was occluded with coil embolization, resulting in resolution of the endoleak.

Conclusion. Our case describes a patient who initially underwent treatment for type 1a endoleak and subsequently developed type 2 endoleak that was successfully treated with coil embolization of the IMA.

J INVASIVE CARDIOL 2011;23:E188–E191

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Endovascular aneurysm repair (EVAR) has developed as a less invasive treatment option for abdominal aortic aneurysm (AAA). Studies have shown that the most important benefits of EVAR are the lower morbidity and mortality in the perioperative period and faster recovery time.^1,2 However, with extended follow-up, newer complications of EVAR have arisen. Among the possible complications, type 2 endoleak is one of the most common. We describe a patient who presented with a recurrent endoleak despite initial intervention and was successfully treated with coil embolization of the inferior mesenteric artery (IMA).

Case Report. A 63-year-old Caucasian male with a past medical history significant for hypertension and dyslipidemia was found to have an AAA during a routine ultrasound of the kidneys. Transverse dimension of the AAA was 7.5 cm. Due to suitable anatomy for percutaneous intervention, the patient was scheduled for EVAR. The patient successfully underwent EVAR with exclusion of the aneurysm sac. Due to a slightly tortuous proximal neck, reinforcement of the proximal neck was performed with balloon angioplasty and stenting. The postprocedure course was uneventful and the patient was discharged home.

As a part of routine follow-up, a computed tomographic (CT) scan was performed 30 days after the procedure, and revealed the presence of a large endoleak with enlargement of the sac. An abdominal aortogram was performed that showed the presence of a type 1a endoleak next to the renal artery ostium (Figure 1, Video 1). The endoleak was successfully repaired with 2 extension cuffs at the proximal end of the stent graft. The procedure resulted in complete resolution of the endoleak (Video 2).

A few months later, CT scan was repeated and revealed a type 2 endoleak without enlargement of the sac; however, there was no reduction in the size of the sac (Figure 2). Multiplanar reconstruction was used and a small branch connecting the superior mesenteric artery (SMA) to the inferior mesenteric artery (IMA) through the marginal artery was found (Figure 3). Repeat angiogram confirmed that IMA was the source of the endoleak (Figure 4 and Video 3). Selective angiogram of the SMA was also performed, which showed filling of the aneurysm sac via the IMA (Figure 5 and Video 4). A microcatheter was advanced through the SMA and marginal artery into the IMA. The IMA was successfully occluded with coil embolization that resulted in complete resolution of the endoleak (Figure 6).

Discussion. Our case describes a patient who initially underwent treatment for type 1a endoleak and subsequently developed type 2 endoleak that was successfully treated with coil embolization of the IMA.

EVAR is a reasonable alternate to open surgical repair in patients with AAA. Data including 6 years of follow-up have shown that endovascular and open repair are associated with similar rates of survival.³ However, the rate of repeat procedures is significantly higher in those with EVAR.³ This increased rate of repeat procedures is due to endoleaks and other complications of EVAR.

Of all the types of endoleak, type 2 endoleak is one of the most common. In a study by Arko et al, independent predictors of type 2 endoleak were patent IMAs, and > 2 lumbar arteries.⁴ Studies regarding the significance of type 2 endoleak have shown mixed results. Some studies have shown that type 2 endoleaks are not associated with adverse outcomes,⁵ whereas other studies have shown that persistent type 2 endoleak is associated with adverse outcomes, aneurysm sac growth, rupture, reintervention, and need for conversion to open repair.⁶ However, most studies are in agreement that type 2 endoleak may result in persistently elevated pressure in the sac and loss of reduction in the sac size.

The ideal modality for follow-up of the EVAR is CT scan, but ultrasound examination may also provide reasonable information in patients with prohibitive conditions for a CT scan.⁷ Reduction in sac size after EVAR is a marker of treatment success.⁸ If there is evidence of increasing sac size or lack of reduction in sac size, intervention must be offered to the patient.⁹ Various treatment options are available for type 2 endoleak. These include endovascular extension grafts, coil embolization, and open surgical repair,¹⁰ but results of secondary interventions after established type 2 endoleak remain poor.¹¹

A growing body of case reports and case series has shown that certain interventions prior to EVAR are associated with a decreased incidence of type 2 endoleak. Embolization of sidebranches arising from the aorta is feasible, associated with high success rate and decreased incidence of type 2 endoleak.¹² Coil embolization of the IMA is also associated with decreased risk of type 2 endoleak.¹³ Fibrin glue injection at the time of EVAR is also safe and has been shown to result in fewer CT examinations and reduced health care costs.¹⁴

In conclusion, our patient initially developed a type 1a endoleak and subsequently developed a type 2 endoleak that was successfully repaired by coil embolization of the inferior mesenteric artery.

Acknowledgment. We are thankful to Dr. Vemuri Babu for his helpful assistance and kind support.

References

1. The EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): Randomized controlled trial. Lancet 2005;365:2179–2186.
2. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004;351:1607–1618
3. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1881–1889.
4. Arko FR, Rubin GD, Johnson BL, et al. Type-II endoleaks following endovascular AAA repair: Preoperative predictors and long-term effects. J Endovasc Ther 2001;8:503–510.
5. Baum RA, Carpenter JP, Cope C, et al. Aneurysm sac pressure measurements after endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2001;33:32–41.
6. Jones JE, Atkins MD, Brewster DC, et al. Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.  J Vasc Surg 2007;46:1–8.
7. Parent FN, Meier GH, Godziachvili V, et al. The incidence and natural history of type I and II endoleak: A 5-year follow-up assessment with color duplex ultrasound scan. J Vasc Surg 2002;35:474–481.
8. Houbballah R, Majewski M, Becquemin JP. Significant sac retraction after endovascular aneurysm repair is a robust indicator of durable treatment success. J Vasc Surg 2010;52:878–883.
9. AbuRahma AF. Fate of endoleaks detected by CT angiography and missed by color duplex ultrasound in endovascular grafts for abdominal aortic aneurysms. J Endovasc Ther 2006;13:490–495.
10. Faries PL, Cadot H, Agarwal G, et al. Management of endoleak after endovascular aneurysm repair: Cuffs, coils, and conversion. J Vasc Surg 2003;37:1155–1161. 
11. Nevala T, Biancari F, Manninen H, et al. Type II endoleak after endovascular repair of abdominal aortic aneurysm: Effectiveness of embolization. Cardiovasc Intervent Radiol 2010;33:278–284.
12. Bonvini R, Alerci M, Antonucci F, et al. Preoperative embolization of collateral side branches: A valid means to reduce type II endoleaks after endovascular AAA repair. J Endovasc Ther 2003;10:227–232.
13. Sheehan MK, Hagino RT, Canby E, et al. Type 2 endoleaks after abdominal aortic aneurysm stent grafting with systematic mesenteric and lumbar coil embolization. Ann Vasc Surg 2006;20:458–463.
14. Pilon F, Tosato F, Danieli D, et al. Intrasac fibrin glue injection after platinum coils placement: The efficacy of a simple intraoperative procedure in preventing type II endoleak after endovascular aneurysm repair. Interact Cardiovasc Thorac Surg 2010;11:78–82.

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From the Department of Cardiology, Saint Joseph Mercy Oakland Hospital, Pontiac, Michigan.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted October 28, 2010 and final version accepted December 13, 2010.
Address for correspondence: Haroon Chughtai, MD, 3220 Bloomfield Lane, Apt. 818, Auburn Hills, MI 48326. Email: eras_27@yahoo.com