Long-term follow-up of type II endoleak embolization reveals the need for close surveillance

ObjectiveAneurysm growth after endovascular aneurysm repair (EVAR) in patients with type II endoleak is associated with adverse outcomes. This study evaluated the long-term success of embolization of type II endoleaks in preventing aneurysm sac growth.MethodsWe retrospectively reviewed outcomes of patients who underwent infrarenal EVAR who were treated for a type II endoleak between 2000 and 2008. Computed tomography scans were evaluated for aneurysm sac growth or shrinkage from the time of treatment of the endoleak. The embolization material used, graft type, target vessel embolized, and comorbidities were evaluated for their association with sac growth or shrinkage.ResultsNinety-five patients underwent 140 embolization procedures. The mean time from EVAR to embolization was 26.1 ± 22.2 months, and the average increase in size of the aneurysm sac from EVAR to treatment was 0.7 × 0.5 cm. Patients underwent an average of 1.6 ± 0.8 embolization procedures after EVAR. Thirteen patients underwent initial simultaneous embolization of two targets. Embolization was with glue (61%), coils (29%), glue and coils (7%), and Gelfoam (3%; Pfizer Inc, New York, NY). No abdominal aortic aneurysms (AAA) ruptured. Eight patients (8.4%) underwent graft explant and open repair; 19 (20%) required two or more embolization procedures. There was no difference in the target vessel treated or the treatment used in halting sac expansion (>5 mm). Coil embolization alone resulted in more second procedures. The 5-year cumulative survival was 65% (95% confidence interval [CI], 52%-77%), freedom from explant was 89% (95% CI, 81%-97%), freedom from second embolization was 76% (95% CI, 66%-86%), and freedom from sac expansion >5 mm was 44% (95% CI 30%-50%). Univariable analysis identified continued tobacco use (hazard ratio [HR], 2.30; 95% CI, 1.02-5.13; P = .04) was associated with continued sac expansion, and hyperlipidemia (HR, 9.64; 95% CI, 2.22-41.86) was associated with patients requiring a second embolization procedure.ConclusionsEmbolization of type II endoleaks is successful early in preventing aneurysm sac growth and rupture after EVAR. However, a significant number of patients require more than one procedure, and at 5 years, many patients who underwent embolization of a type II endoleak continued to experience sac growth. Patients with hyperlipidemia who undergo coil embolization are more likely to require a second embolization procedure, and patients who smoke have a higher likelihood of AAA sac expansion after embolization. Continued long-term surveillance is necessary in this cohort of patients

Use of fascia-peritoneum patch as a pledget for an infected aortic stump

AbstractTreatment of aortic prosthetic graft infections remains a challenge. One frequently encountered technical difficulty when removing an infected prosthetic aortic graft is how to close a short, friable remnant aortic stump. We present three case reports in which we used a layer of posterior rectus fascia-peritoneum to bolster oversewing a short infected aortic stump after removal of an infected aortic graft. All three patients underwent staged extra-anatomic axillary-to-femoral artery bypass procedures, with subsequent removal of the infected aortic graft as a second operation. Two of the three procedures were semi-elective, and one was done urgently because of a recurrent aortoenteric fistula. All three patients had less than 1 cm of remaining aortic neck below the renal arteries for closure. In each instance a segment of autogenous posterior rectus fascia-peritoneum was harvested and used as a circumferential pledget to bolster the anastomosis. No patient had stump blowout, and in no case was there computed tomography evidence of aneurysmal enlargement of the stump with follow-up of 12 and 24 months in two of the three survivors. Use of autogenous fascia-peritoneum is a durable and effective method to assist stump closure and prevent stump blowout after removal of infected aortic grafts

Repair of a mycotic abdominal aortic aneurysm in a neonate using an everted jugular vein patch

A 43-day-old boy presented with bacteremia after umbilical artery catheterization. Duplex ultrasound examination revealed a 1.1- × 1.6-cm mycotic infrarenal aortic aneurysm and an incidental asymptomatic occluded right common iliac artery. Resection and repair were completed by creating an everted, double-layered internal jugular vein patch. Screening ultrasound examination 10 months postoperatively demonstrated successful repair