Mauro Gargiulo

Type IA EL – Decision making, treatment, tips and tricks

Vascular Surgery

University of Bologna - DIMES

University Hospital, Policlinico S.Orsola

Bologna, Italy

mauro.gargiulo2@unibo.it

Disclosure

Speaker name: Prof. Mauro Gargiulo

I have the following potential conflicts of interest to report:

X Consulting: Cook Medical

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

Type IA EL – Decision making, treatment, tips and tricks

Endoleak Type Origin of the leak

I Inadeguate seal at the proximal (IA) or distal (IB) end of the stent graft

II Retrograde flow from the inferior mesenteric artery, lumbar arteries, others collateral

vessels of the aneurysm sac

III Component disconnection (IIIa) or fabric disruption (IIIb)

IV Graft material porosity

V Endotension: increase of the pressure without any visible evidence of blood in the

aneurysm sac

Moll FL et al.

Eur J Vasc Endovasc Surg 2011; 41 Suppl 1: S1-S58

Conversion to open repair after endografting for AAA:A review of causes, incidence, results and surgical techniques of reconstruction

Moulakakis KD et al.

J Endovasc Ther 2010; 17: 694-702

Early Conversion Late Conversion

Incidence (mean) 0.3%-5.9% (1.5%) 0.4% - 22% (1.9%)

Mortality rate (mean) 0 – 28.5% (12.4%) 0 – 20% (10%)

Predictive factor Female gender Type I/II endoleak, graft

migration, kinking

Causes 1.Technical failure on deployment- severe iliac arteries

- inability to catheterize controlateral limb

-incorrect deployment of the stent-grafte

- insufficient connection of the variuos parts

2. Inappropriate stent graft placement- graft migration

- type I endoleak

- high deployment with renal arteries coverage

3. Vessel rupture- iliac arteries

- abdominal aorta

4. Graft thrombosis

1. Aneurysm expansion- type I/II/III endoleak

- stent-graft migration

2. Persistent endoleak

3. Endograft thrombosis

4. Graft infection

J Vasc Surg 2019;69(2):423-431

Ann Vasc Surg 2020 in press

• Proximal Aortic Cuff Extensions

• Endoanchor ± Proximal Aortic Cuff Extensions

• Primary stenting / graft balloon dilatation

• Embolization

• Chimney Technique

• F-BEVAR

Late Type IA EL - Endovascular Treatment

Vascular Surgery – University of Bologna, Italy

•Appropriate infrarenal sealing zone to achieve a seal

– Proximal Aortic Cuff Extensions

– Endoanchor ± Proximal Aortic Cuff Extensions

– Primary stenting / graft balloon dilatation

– Embolization

• No infrarenal sealing zone

– Chimney Technique

– F-BEVAR

Vascular Surgery – University of Bologna, Italy

Late Type IA EL - Endovascular Treatment

• No infrarenal sealing zone

– Chimney Technique

• Off – the – shelf

• Treatment of choice in urgent cases

Vascular Surgery – University of Bologna, Italy

Late Type IA EL - Endovascular Treatment

• No infrarenal sealing zone

– Chimney Technique

• Off – the – shelf

• Treatment of choice in urgent cases

• TS: 93.9% (Perini et al Ann Vasc Surg 2020)

• Treatment of choice in elective cases with 1-2 chimneys configuration

Collected Transatlantic Experience from PERICLES Registry:

Use of Chimney graft to treat post-EVAR Type IA endoleaks shows good midterm resultsRonchey S et al; J Endovasc Ther 2018; 25(4):492-8

• Pts 39

• Chimney graft pacement: 1 (18-46%), multiple (21-54%)

• TS: 89.7%

• 30-day mortality: 2.6%

• Primary patency chimey grafts at 3 years: 94.3%

Late Type IA EL - Endovascular Treatment

Gutters

✓ Persistent endoleak

✓ Aneurysm diameter 90

mm

✓ Abdominal pain

85 yrs old, High risk for OR (SVS reporting standard 2017)

Vascular Surgery – University of Bologna, Italy

RA

branch

Proximal sealing

+150 mm

Alma Mater Studiorum – University of Bologna

85 yrs old, High risk for OR (SVS reporting standard 2017)

Vascular Surgery – University of Bologna, Italy

CTA @ 30-day

85 yrs old, High risk for OR (SVS reporting standard 2017)

Vascular Surgery – University of Bologna, Italy

• No infrarenal sealing zone

– F/BEVAR

• Custom-made devices

• TS: 86.2% (Perini et al Ann Vasc Surg 2020)

• Treatment of choice in elective cases

Vascular Surgery – University of Bologna, Italy

Late Type IA EL - Endovascular Treatment

Ann Vasc Surg 2016; 32:119-127.

J Vasc Surg 2018;66(6): 1676-1687

End Points Explantation F/BEVAR p

Technical Success = = .266

Cardiac complications

Renal complications

Pulmonary complications

.010

.0002

0.0002

Access-related

complications

.009

In-hospital mortality .021

30-day mortality 0.19

30-day reinterventions = = .411

J Vasc Surg 2018;66(6): 1676-1687

Type IA Endoleak– Endovascular treatment with F-BEVAR

• dislocation of iliac limb

• dislocation of iliac stent

• difficult cannulation of visceral vessels

Technical Problems

Device and Stent-graft configuration

• double reducing ties

• controlateral inverted limb

Vascular Surgery – University of Bologna, Italy

Type IA Endoleak– Endovascular treatment with F-BEVAR

• dislocation of iliac limb

• dislocation of iliac stent

• difficult cannulation of visceral vessels

Technical Problems

Device and Stent-graft configuration

• double reducing ties

• controlateral inverted limb

Vascular Surgery – University of Bologna, Italy

Type Ib endoleak

Dislocation of iliac limb by F-B/EVAR introduction

Vascular Surgery – University of Bologna, Italy

• dislocation of iliac limb

• dislocation of iliac stent

• difficult cannulation of visceral vessels

Type IA Endoleak– Endovascular treatment with F-BEVAR

Technical Problems

Device and Stent-graft configuration

• double reducing ties

• controlateral inverted limb

Vascular Surgery – University of Bologna, Italy

Dislocation of iliac leg stent by F-B/EVAR introduction

Vascular Surgery – University of Bologna, Italy

Vascular Surgery – University of Bologna, Italy

Genesis

FB-EVAR

Vascular Surgery – University of Bologna, Italy

Vascular Surgery – University of Bologna, Italy

Intraoperative Angio Peri-operative CTA

Vascular Surgery – University of Bologna, Italy

Vascular Surgery – University of Bologna, Italy

• dislocation of iliac limb

• dislocation of iliac stent

• difficult cannulation of visceral vessels

Type IA Endoleak– Endovascular treatment with F-BEVAR

Technical Problems

Device and Stent-graft configuration

• double reducing ties

• controlateral inverted limb

Vascular Surgery – University of Bologna, Italy

The is a steerable

guiding sheath that offers a def ectable tip with

an ergonomic handle. The Destino™ Twist is the

ultimate tool for gaining access to the most di f cult

to reach sites, while maintaining hemostasis with

Oscor SureSeal™ technology. The Destino ™ Twist

is YOUR ONE SHEATH SOLUTION intended to

facilitate the intracardiac, renal, and peripheral

placements of diagnostic and therapeutic devices.

8.5 F

(2.80 mm)

9.5 F

(3.20 mm)

(2.20 mm) (2.50 mm)

2.20 mm 2.40 mm

6.5 F 7 F

TIP TIP

12 F

(4.00 mm)

(2.90 mm)

2.80 mm

8.5 F

TIP

Smooth tip to dilator

transition

Clear view of the distal

marker band under

f uoroscopy

Hydrophobic coated

sheath

Braided Flexsteer™

shaft technology

Tip position indicator

Rotating collar

French size and

guidewire indicator

Reliable SureSeal ™

hemostatic valve

StandardTichà Damascelli (TD) Curve

SHAFT MODELS

SHAFT DIAMETERS

9 mm 17 mm

TIP DEFLECTION

Vascular Surgery – University of Bologna, Italy

Ann Vasc Surg 2020 in press

• dislocation of iliac limb

• dislocation of iliac stent

• difficult cannulation of visceral vessels

Type IA Endoleak– Endovascular treatment with F-BEVAR

Technical Problems

Device and Stent-graft configuration

• double reducing ties

• controlateral inverted limb

Vascular Surgery – University of Bologna, Italy

Reducing Tie System

G. Oderich 2018

• dislocation of iliac limb

• dislocation of iliac stent

• difficult cannulation of visceral vessels

Type IA Endoleak– Endovascular treatment with F-BEVAR

Technical Problems

Device and Stent-graft configuration

• double reducing ties

• controlateral inverted limb (composed biforcated)

Vascular Surgery – University of Bologna, Italy

Long previous

graft

Inverted Limb

Juxtarenal and pararenal AAAs with a previous abdominal prosthesis:

Results of endovascular conversions with F/BEVAR Endograft

Vascular Surgery – University of Bologna, Italy

Conclusions

• Type IA EL happens when there is an inadequate seal at the proximal end of stent-graft

• Type IA EL is associated with an increase of sac pressure and risk of AAA rupture

• Type I A EL should be treated promptly

• Re-intervention to achieve a seal, primarily by endovascular means, is recommended

• The endovascular choice should be based on appropriate landing zone to achieve a seal

Vascular Surgery – University of Bologna, Italy

Type IA EL – Decision making, treatment, tips and tricks

Mauro Gargiulo

Type IA EL – Decision making, treatment, tips and tricks

Vascular Surgery

University of Bologna - DIMES

University Hospital, Policlinico S.Orsola

Bologna, Italy

mauro.gargiulo2@unibo.it