DISCLOSURES

NEW INNOVATIONS IN • Nothing to disclose

ENDOLEAK MANAGEMENT
Kelley Hodgkiss-Harlow, MD, RPVI, FACS
Vascular and Endovascular Surgery
Kaiser Permanente, San Diego

GOALS BACKGROUND
• Background • Majority of AAA repair is done
• Surveillance Guidelines endovascularly
• Type I endoleaks • SVS practice guidelines (JVS 2009)
• Chimneys/snorkels • CTA at one month post EVAR
• FEVAR • If no endoleakone year
• Endofixation • If endoleak or abnormality6
months
• Type II endoleaks • Color duplex ultrasonography or
• Significance? noncontrast imaging in renal failure
• Prevention? • Lifelong Surveillance
• Type III endoleaks • Change in position of endograft?
• relining • Status of aneurysm sac?
• “other” fixes • Endoleak?

BACKGROUND
LIFELONG SURVEILLANCE
• Maldeployment
• Inadequate Sizing
• Graft Migration
• Anatomic remodeling

• Patients lost to followup have much

poorer survival than patients who
have in-person followup after EVAR
• 85% versus 92%
• Thought to be due strictly to
surveillance postoperative scans

JVS June 2017 vol 65: 6, 1625-35 Endovascular aneurysm repair patients who are lost to follow-up have worse outcomes. Malas et al.
The Place of Endovascular Treatment in Abdominal Aortic Aneurysm. Dtsch Arztebl Int 2013; 110(8): 119-25

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 ENDOLEAKS:
TYPE IA ENDOLEAKS
LIFELONG SURVEILLANCE • Incomplete/ineffective seal at
proximal or distal end of graft
• 880 patients with EVAR 1999-2015 • Freedom from reintervention
• Endograft migration downwards
• Sac shrinkage/expansion • 95.6% 2 years
• Reintervention • 94.1% 4 years • AneuRx
• 90.4% 6 years • Aneurysm
• New endoleaks appeared during the morphology/anatomy changes
entire follow-up of the study • 87.1% 8 years
• Endoleaks evolved to requiring • 86.4% 10 years • Goal of repair to improve proximal
reinterventions in nearly 1/3 of patients • 82.1% 12 years fixation
• Type I • 80% 14 years • Endograft cuff
• Presence limb stenosis/thrombosis • 6 deaths • Suprarenal fixation
• Age >65 years • 2 sac rupture with type I endoleak • Palmaz stenting
• Active smoking • Overall survival 94.5% 2 years, 33.3% 14 • Anchoring devices
• Sac expansion years

JVS June 2017: Vol 65, Issue 6, page 44S. Long-Term Analysis of Endoleak Onset and Evolution Following Abdominal Aortic Endovascular Repair Using Multiple Grafts: Michelagnoli et al
Aortic Aneurysm-Recent Advances. Ch 8. Jing et al.

TYPE IA ENDOLEAK
TYPE IA ENDOLEAKS
• Treatment - Sac Enlargement
• Palmaz Stenting
• Open Ligation
• Proximal Cuff

TYPE IA ENDOLEAK:
TYPE IA: SNORKEL/CHIMNEYS
CHIMNEYS/SNORKELS
• Snorkels/Ch-EVAR • Time to presentation avg 6 years
• Attempt to increase proximal neck • 19 patients with type I endoleak
length through the use of stents into requiring Ch-EVAR as salvage •DEVICE SELECTION
visceral vessels procedure •20–30% oversizing of cuff based on max diameter at base
• 60 pts111 snorkel stents • 18 cuff with parallel visceral stents of superior mesenteric artery
• Gutter leaks as high as 30% in the • 1 relining with parallel visceral stents •Adequate neck to achieve a minimum of 1.5 cm of new
seal
early postoperative period • 29 new total stent grafts placed •1-mm oversizing for renal vessels
• Spontaneous resolution • Primary technical success 100% •Access left brachial versus left axillary artery
• 65% within 1 year •Preference for cuffs with suprarenal fixation based on
• 88% within 18mos • Reintervention in one patient for distance of main body endograft from lowest renal artery
new type III endoleak
• Reintervention rate of 3.3%
• 18month follow up with 100% snorkel
patency

JVS 2017 Vol 65, Iss 4 981-990. Ullery et al. Natural History of gutter-related type Ia endoleaks after snorkel/chimney endovascular aneurysm repair. Annals Vasc Surg 2017: Tanious et al. Endovascular Management of Proximal Fixation Loss Using Parallel Stent Grafting Techniques to Preserve Visceral Flow

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 TYPE IA: PROTOCOL TYPE IA: FEVAR
• Salvage with FEVAR
• Length often prohibitive to reline
depending on level of migration
• Solution—fevar (Renu) cuff
• Case reports--3 patients
• 6 renals
• 3 SMAs
• 1 celiac
• 12 month follow up demonstrated
100% patency with no endoleak

Annals Vasc Surg 2017: Tanious et al. Endovascular Management of Proximal Fixation Loss Using Parallel Stent Grafting Techniques to Preserve Visceral Flow JVS 2006;44:1341-4. Adam et al. Salvage of failed prior endovascular abdominal aortic aneurysm repair with fenestrated endovascular stent grafts

TYPE IA: FEVAR II TYPE IA: FEVAR III

• 26 pts Netherlands/Germany • Target vessel patency 100% (70)
• 2002-2012 • 4 required reintervention
• 23 fenestrated cuff • Rupture, iliac limb occlusion, type Ib
• 3 bifurcated stent graft and type II endoleak
• Mean follow up 26.8 mos • Increased technical challenges
• Technical success 92% secondary to previously placed
• 1 on-table open conversion stent graft (11 cases with
• 1 lost renal catheterization difficulties)
• No Type Ia endoleak on first CTA • Outcome seemed related to initial
technical success
• Device availability in USA--??

EJVS May 2013: Katsargyris et al. Fenestrated Stent-grafts for Salvage of Prior Abdominal Aortic Aneurysm Repair EJVS May 2013: Katsargyris et al. Fenestrated Stent-grafts for Salvage of Prior Abdominal Aortic Aneurysm Repair

TYPE IA ENDOLEAKS:
ENDOFIXATION Table IV Endografts in the primary and revision arms
• ANCHOR registry
• 319 patients, 43 sites, 23months Primary arm (n = 242), Revision arm (n = 77),
All (N = 319), No. (%)
• EndoAnchors implanted proximally No. (%) No. (%)
• 242 pts at time of initial procedure
Gore Excluder 86 (35.5) 16 (20.8) 102 (32.0)
• Revision arm: 77 patients
• Existing endograft with proximal aortic Cook Zenith 40 (16.5) 11 (14.3) 51 (16.0)
neck complications Medtronic Endurant 112 (46.3) 10 (13.0) 122 (38.2)
Medtronic AneuRx 0 18 (23.4) 18 (5.6)
• 7 pts (9%) in revision arm required Medtronic Talent 0 14 (18.2) 14 (4.4)
secondary intervention for residual type Ia Other 4 (1.7) 8 (10.4) 12 (3.8)
endoleak
• 2 technical device failures in total
• Fractured or incomplete penetration
of screw

JVS 2014;60:885-892. Jordan et al. Results of the ANCHOR prospective, multicenter registry of
EndoAnchors for type Ia endoleaks and endograft migration in patients with challenging anatomy.

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 Table VI Secondary procedures

Secondary procedure Primary arm (n = 242), No. (%) Revision arm (n = 77), No. (%) All (N = 319), No. (%)

Open surgical conversion 0 0 0 ENDOFIXATION DEVICES

Repair of type Ia endoleak 1 (0.4) 7 (9.1) 8 (2.5)

Treatment of type II endoleak 1 (0.4) 4 (5.2) 5 (1.6) • Conclusions:

• Couldn’t hurt (low complication
Treatment of migration 0 0 0
rate, user-friendly)
Treatment of graft limb kinking 1 (0.4) 1 (1.3) 2 (0.6) • Might help
• Should we be placing these on
Treatment of graft limb occlusion 2 (0.8) 1 (1.3) 3 (0.9)
every EVAR as prophylaxis?
Treatment of access vessel injury 1 (0.4) 0 1 (0.3)

Lower extremity revascularization 2 (0.8) 1 (1.3) 3 (0.9)

Total secondary proceduresa 7 (2.9) 11 (14.3) 18 (5.6)

Total patients with secondary

7 (2.9) 7 (9.1) 14 (4.4)
procedures

JVS 2014;60:885-892. Jordan et al. Results of the ANCHOR prospective, multicenter registry of
EndoAnchors for type Ia endoleaks and endograft migration in patients with challenging anatomy.

TYPE II ENDOLEAKS TYPE II ENDOLEAKS

• Retrograde blood flow from an aortic branch vessel • 693 pts 2009-2013 Australia Parameter
Age
Label HR*
1.05
Lower CL
1.02
Upper CL
1.08
P
0.0008

• IMA • 225 pts developed type II endoleaks Gender

Male
Female
1.00
1.58
-
0.85
-
2.91
-
0.146

• Lumbar • 133 spontaneously resolved Statin

Statin (yes)
Statin (no)
1.00
1.64
-
1.07
-
2.52
-
0.024

• Middle sacral • 37 untreated unresolved Beta blocker

Beta blocker
(yes) 1.00 - - -
Beta blocker 0.94 0.61 1.45 0.774
• Accessory renal arteries • 16 underwent intervention (no)
ASAII 1-2 1.00 - - -
ASAII
• Reported incidences vary widely in literature • Smoking and warfarin protective Smokes
ASAII 3-4
Never
1.56
1.00
0.86
-
2.82
-
0.143
-
Ex-smoker 1.77 0.90 3.49 0.100
• 3-40% (p=0.052)
Current 2.50 1.19 5.29 0.016
• Age, R iliac artery tortuosity, and Warfarin (yes) 1.00 1.00 1.00 -
• Most commonly between 10-20% Warfarin
Warfarin (no) 0.86 0.46 1.61 0.644
large external iliac artery diameters Aneurysm
1.01 0.99 1.04 0.1669
• Increased chance of developing type II were risk factors
diameter
RCIA
0.99 0.95 1.03 0.7188
diameter
• Mural thrombus LCIA diameter 1.01 0.97 1.06 0.5070

• Patent aortic branch vesels

REIA diameter 0.96 0.85 1.08 0.4789
LEIA diameter 0.96 0.86 1.08 0.5398

Annals Vasc Surg 2017 Article in Press: Type II Endoleak After Endovascular Aneurysm Repair: natural history and treatment outcomes

TYPE II ENDOLEAKS
All Sac expansion >5mm † No Sac expansion >5mm
TYPE II ENDOLEAKS
Late
type 2
Total
Mortalit Interve
y ntion
Total
Mortalit Interve
y ntion
Total
Mortalit Interve
y ntion
CAN/SHOULD WE PREVENT THEM?
117 ‡ 24 25 26 5 10 91 19 15
endole

• 3 ruptures in cohort • Preemptive embolization of sac

aks *
No late
type 2
endole
aks
458 70 36 25 8 3 433 62 33
• 2 after type II endoleak • Coils, fibrin glue
reintervention and in absence of
sac expansion • 72 pts 2011-2014
• 36 with, 36 without
• 117 endoleaks occurred late (>30
days) • Group without embolization
• 9 type II, 1 type Ia
• Conclusions:
• Sac expansion not associated with • Group without embolization
rupture • 2 type II, 1 type Ib
• Survival unaffected by presence of • Average cost 7500 euro more
type II
• Avg exposure time 13 min more

Annals Vasc Surg 2017 Article in Press: Type II Endoleak After Endovascular Aneurysm Repair: natural history and treatment outcomes Annals Vasc Surg 2017 Article in press: Massimiliano et al. Embo-EVAR: a technique to preent type II endoleak? A single-centre experience

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 TYPE III ENDOLEAKS TYPE III ENDOLEAKS
• Relining the graft • Incidence is fairly rare with most • Variety of stent grafts
endografts • Stentor
• Cuff or limb • 965 EVAR procedures over 20 years • Vanguard
(France/Belgium) • Zenith
• Sometimes the whole graft! • 20 type III leaks identified (2.1%) • Excluder]
• Pros: morbidity minimal with • Median interval between EVAR and • Talent
endovascular repair diagnosis was 5.6 years (0-13 years) • AneuRx
• 88% managed endovascularly • Endurant
• Pitfalls: contrast usage • AUI: 5 (20%) • Ovation
• Sometimes lengths preclude repair • Limb extension: 7 (28%) • Anaconda
without getting creative • Covered stent placement: 8 (32%) • Independent risk factors:
• Aortic cuff: 1 (14%) • 1st and 2nd generation endografts
• 25% recurring

JVS 2017 Article in Press: Incidence, etiology, and management of Type III endoleak after endovascular aortic repair. Rousseau et al.

TYPE IIIA ENDOLEAKS:

• Contributing factors (modular
disconnect)
• Inadequate component overlap at
index procedure
• Lateral movement in large or
tortuous aortas leading to reduction
or loss of component overlap
• Excessively oversized proximal
extension relative to bifurcated
main body device.
• Preventative: better device
selection with emphasis on
maximizing overlap

JVS June 2105 Skibba et al. Management of late main-body aortic endograft component uncoupli
type IIIa endoleak encountered with Endologix Powerlink and AFX platforms

TYPE III ENDOLEAKS TYPE IIIB ENDOLEAKS: AFX

• Reline graft by traversing • Contributing factors (thin graft
material)
components and • Guidewire/catheter manipulation
extending and aggressive balloon molding
• Off-label use in highly calcified
anatomy
• Conversion to AUI and • Lateral movement/changes in
implant stability\
plug • Other devices proximal extensions

SCVS 2016: Endosalvage Techniques – Relining of Infrarenal EVAR as a solution for High-Pressure Endoleak. Inui et al.

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 OTHER SOLUTIONS TO TYPE IIIB…
• 4 year old fenestrated Cook graft
• Aneurysm growth 5.36.7cm
• Angiography with selective
catheterization revealed type IIIb
endoleak in proximal graft
• Not considered for open repair
given comorbidities.
• Endovascular relining difficult given
fenestrations of SMA/RRA
• Defect sized with balloon, then
amplatzer plug “fills” the hole.

J Endovasc Ther 2017 Vol 24(2) 262-264. McWilliams et al. Endovascular Repair of Type IIIb Endoleak with the Amplatzer Septal Occluder

CONCLUSIONS
• Endoleak management is
continually evolving with new
technology and new challenges
• Old standbys still work….
• Innovative techniques demand a
critical eye
• (and randomized controlled trials)
• “Newest” doesn’t always mean
“best”