CISCATO JUNIOR, José Geraldo

DALIO, Marcelo Bellini

DEZOTTI, Nei Rodrigues Alves

JOVILIANO, Edwaldo Edner

MORIYA, Takachi

PICCINATO, Carlos Eli

Edwaldo Edner Joviliano

Marcelo Bellini Dalio

José Geraldo Ciscato Junior

Nei Rodrigues Alves Dezotti

Takachi Moriya

Carlos Eli Piccinato

Directory of Open Access Journals

Jornal Vascular Brasileiro

Endovascular treatment of endotension with dacron stent graft reinforcement and femorofemoral crossover bypass: therapeutic challenge Tratamento endovascular da endotensão com endoprótese de dácron e derivação femoro-femoral cruzada: desafio terapêutico

Biblioteca Digital da Produção Intelectual da Universidade de São Paulo (BDPI/USP)

THERAPEUTIC CHALLENGE
Endovascular treatment of endotension with dacron stent 
graft reinforcement and femorofemoral crossover bypass - 
therapeutic challenge
Tratamento endovascular da endotensão com endoprótese de dácron e derivação femoro-
femoral cruzada - desafio terapêutico
Edwaldo Edner Joviliano1, Marcelo Bellini Dalio2, José Geraldo Ciscato Junior2, Nei Rodrigues Alves Dezotti2, 
Takachi Moriya1, Carlos Eli Piccinato3
Part I - Clinical case
A 54 year-old man with an asymptomatic 5.9 cm AAA 
was treated with an Excluder® 26 mm/14.5 mm/16 cm 
endoprosthesis (Gore, USA). Initial aortic morphology 
showed a proximal neck of 2.0 cm of extension by 23 mm 
of diameter. The common iliac arteries measured 13 mm 
in right diameter and 12 mm in left diameter. No endoleak 
was detected immediately after the procedure.
One month after the procedure, computed tomog-
raphy (CT) scan showed maintenance of aneurysmal di-
ameters without evidence of endoleak (Figure 1). After 
one year, follow-up duplex ultrasound and CT scan 
showed no endoleak, but a small growth of the aneurys-
mal sac to 6.2 cm was observed (Figure 2). Aortography 
with selective visceral and hypogastric arteries showed 
no endoleak (Figure 3). We decided to observe the out-
come of the condition with a second CT scan within six 
months. The patient only returned after one year, when 
CT scan found the aneurysmal diameter had increased 
to 7.5 cm, but without evidence of endoleak. The case 
was interpreted as endotension, and intervention was 
considered. Since the patient presented class II heart fail-
ure, poorly controlled cardiac arrhythmia and a previous 
left pneumonectomy for a neoplasm, an endovascular 
approach was chosen.
Part II - What was done?
Endovascular intervention was performed using a right 
aorto-mono-iliac Zenith® endoprosthesis (Cook, USA) 28 
mm/125 mm with and extension 12 mm/88 mm deployed 
inside the previous one and an occluder 14 mm/20 mm for 
the left iliac artery. Pre-procedure aortography showed no 
evidence of endoleak. After endograft deployment, a fem-
oro-femoral crossover left-right bypass graft with 8 mm 
PTFE was carried out. No complication was noted and the 
patient was discharged after two days.
After six months, a new CT scan showed an aneurys-
mal diameter of 6.5 cm, i.e., a reduction of 1 cm compared 
with the pre-intervention exam (Figure 4).
CT scan studies were all performed using a 16-slice he-
lical scanner. All series, including noncontrast images, were 
obtained at 5.0 mm thickness. Arterial phase images were 
obtained at 3.0 mm thickness and later reconstructed at 1.5 
mm thickness. 
The mechanism of persistent sac pressurization without 
endoleak has yet to be explained. It seems to be the result of 
Keywords: Aortic aneurysm, blood vessel prosthesis, vascular surgical procedures endotension.
Palavras-chave: Aneurisma aórtico, prótese vascular, procedimentos cirúrgicos vasculares, endotensão.
1 Professor Associado, Divisão de Cirurgia Vascular e Endovascular, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), 
Ribeirão Preto, SP.
2 Médico Assistente, Divisão de Cirurgia Vascular e Endovascular, Departamento de Cirurgia e Anatomia, FMRP, USP, Ribeirão Preto, SP.
3 Professor Titular, Divisão de Cirurgia Vascular e Endovascular, Departamento de Cirurgia e Anatomia, FMRP, USP, Ribeirão Preto, SP.
No conflicts of interest declared concerning the publication of this article.
Manuscript received Oct 27 2009, accepted for publication Mar 23 2010.
J Vasc Bras. 2010;9(2):81-84.
Endovascular treatment of endotension - Joviliano EE et al.J Vasc Bras 2010, Vol. 9, Nº 282
Figure 1 - Computed tomography angiography at one month without 
evidence of endoleak
Figure 2 - Computed tomography angiography showing increase in 
aneurysm sac diameter
Figure 3 - A) Aortography and B) selective angiography showing no endoleak
altered the design of the Excluder® with the aim of decreas-
ing porosity; the effect of this change on reducing the in-
cidence of endotension is still under investigation. Recent 
work has showed that sac behavior after EVAR with this 
newer low-permeability Excluder® endoprosthesis is signif-
icantly improved compared with the previous one. This new 
design may be a solution for the endotension problem.11
Treatment for patients with endotension remains con-
troversial. Mennander et al.12 proposed a nonoperative ap-
proach for endotension. In their study, three patients pre-
sented ruptured aneurysm during the follow-up, without 
associated hemorrhage, confirming a continuous increase 
in sac size and aneurysm wall tension in the presence of 
an effective endograft seal. Evidently, sac enlargement is 
not always associated with blood flow inside the sac, and 
continuous filtration of transudative material through the 
pressure transmission and fluid accumulation facilitated by 
increased graft porosity, like that observed in the original 
PTFE from the Gore Excluder® device.8 Kotke-Marchant 
et al.9 demonstrated that graft fabrics could activate leuko-
cytes and the complement system to varying degrees: PTFE 
exhibited minimal complement activation and leukocyte 
adhesion, but dacron strongly activated both complement 
and leukocytes. Trocciola et al.,10 reported transudation of 
serum components in an animal model of aortic aneurysm 
that had been excluded with an expanded PTFE stent graft. 
By comparison, aneurysm exclusion with a dacron stent 
graft resulted in significantly less pressure transmission 
in the aneurysm sac and demonstrated greater thrombus 
organization. Gore Excluder® has been shown to have a 
lower incidence of aneurysm sac shrinkage. Melissano et al 
showed an incidence of 37% for Excluder®.8 In 2004, Gore 
Endovascular treatment of endotension - Joviliano EE et al. J Vasc Bras 2010, Vol. 9, Nº 2 83
graft may result in sac rupture. The fact that the aneurys-
mal sac can burst because of endotension and the poorly 
understood consequences of this rupture make conserva-
tive treatment fail as a better choice for such patients. A 
recent consensus recommended that aneurysmal sac en-
largement associated with endotension needs to be treat-
ed.13 Open surgery can be a definitive solution, but it can 
be difficult to recommend it because of the surgical risk of 
most of these patients.
Different authors have described techniques with-
out aortic cross clamping and other less invasive options. 
Risberg et al.5 reported that puncture, fenestration or resec-
tion of the sac did not seem to be adequate. Mory et al.14 
suggested an open surgical approach based on decompres-
sion and fenestration of the aneurysm sac, proximal aortic 
neck banding, and transmural endograft fixation with good 
results in three cases. However, this technique did not ob-
viate major laparotomy and did not exclude the endograft 
that retained its porosity.
Various authors have proposed treatment with en-
dograft relining with satisfactory results. Goodney & 
Fillinger15 reported nine cases using another Excluder® 
device with a mean follow-up of 16 months, in which 
mean diameter decreased 2.0 mm/year and mean sac vol-
ume decreased 2.6% per year. They argued for a selective 
strategy in three ways: reline limbs only; reline limbs only 
and advance the bifurcation; and reline with aortic cuff 
and limbs. It depends on the parts in contact with the 
sac. Kougias et al.6 also reported cases of endograft relin-
ing with another Excluder® component. The use of aortic 
cuffs and limbs clearly does not totally eliminate contact 
between the relatively porous PTFE graft and flowing 
blood. The authors believe that the dynamic process of 
transudation and resorption would be tipped in favor of 
resorption. Sac expansion appeared to be arrested by re-
lining the high-permeability device with low-permeability 
Excluder® endoprosthesis components. Conversely, the 
nature of the original expansion pattern makes it difficult 
to declare that the relining procedure with another PTFE 
is a definitive solution for endotension.
In our report we did not detect any previous endole-
ak and the patient was not submitted to any intervention 
other than aortouniiliac endograft with femorofemoral 
crossover bypass. We describe a technique with total ex-
clusion of the previous components using a graft with 
known low permeability, such as dacron from Zenith® 
graft. Smith et al. showed a rapid sac diameter decrease 
of 41 mm in six months.7 In our case, the sac decreased 
by 10 mm in six months. This case reports a valuable 
minimally invasive option for patients with endotension 
and an alternative to open surgical conversion or relin-
ing with another PTFE graft.
In conclusion, an increase in aneurysmal sac diam-
eter by endotension after EVAR is an indication for inter-
vention. For patients with advanced age or poor clinical 
conditions, a minimally invasive technique may be more 
suitable than open surgical conversion. Endovascular 
treatment of endotension with dacron stent graft seems to 
be a safe and efficient alternative to relining with another 
PTFE stent graft.
References
1. EVAR trial participants. Endovascular aneurysm repair versus open 
repair in patients with abdominal aortic aneurysm (EVAR trial 1): 
randomized controlled trial. Lancet. 2005;365:2179-86.
2. EVAR trial participants. Endovascular aneurysm repair and out-
come in patients unfit for open repair of abdominal aortic 
aneurysm (EVAR trial 2): randomized controlled trial. Lancet. 
2005;365:2187-92.
3. Gilling-Smith G, Brennan J, Harris P, Bakran A, Gould D, McWilliams 
R. Endotension after endovascular aneurysm repair: definition, 
classification, and strategies for surveillance and intervention. J 
Endovascular Surg. 1999;6:305-7.
4. Fillinger M. Three-dimensional analysis of enlarging aneurysms af-
ter endovascular abdominal aortic aneurysm repair in the Gore 
Excluder Pivotal clinical trial. J Vasc Surg. 2006;43:888-95.
Figure 4 - Computed tomography angiography at six months after new 
endovascular procedure showing aneurysm sac shrinkage
Endovascular treatment of endotension - Joviliano EE et al.J Vasc Bras 2010, Vol. 9, Nº 284
5. Risberg B, Delle M, Lönn L, Syk I. Management of aneurysm sac 
hygroma. J Endovasc Ther. 2004;11:191-5.
6. Kougias P, Lin PH, Dardik A, Lee WA, El Sayed HF, Zhou W. 
Successful treatment of endotension and aneurysm sac enlarge-
ment with endovascular stent graft reinforcement. J Vasc Surg. 
2007;46:124-7.
7. Smith ST, Clagett GP, Arko FR. Endovascular conversion with femo-
rofemoral bypass as a treatment of endotension and aneurysm sac 
enlargement. J Vasc Surg. 2007;45:395-8.
8. Melissano G, Bertoglio L, Esposito G, Civilini E, Setacci f, Chiesa 
R. Midterm clinical success and behavior of the aneurysm sac af-
ter endovascular AAA repair with the Excluder graft. J Vasc Surg. 
2005;42:1052-7.
9. Kottke-Marchant K, Anderson JM, Miller KM, Marchant RE, 
Lazarus H. Vascular graft associated complement activation and 
leukocyte adhesion in an artificial circulation. J Biomed Mater Res. 
1987;21:379-97.
10. Trocciola SM, Dayal R, Chaer RA, et al. The development of en-
dotension is associated with increased transmission of pressure 
serous components in porous expanded polytetrafluoroethylene 
stent-grafts: characterization using a canine model. J Vasc Surg. 
2006;43:109-16.
11. Tanski W 3rd, Fillinger M. Outcomes of original and low-permea-
bility Gore Excluder endoprosthesis for endovascular abdominal 
aortic aneurysm repair. J Vasc Surg. 2007;45:243-9.
12. Mennander A, Pimenoff G, Heikkinen M, Partio T, zeitlin R, 
Salenius JP. Nonoperative approach to endotension. J Vasc Surg. 
2005;42:194-9.
13. Veith FJ, Baum RA, Ohki T, et al. Nature and significance of en-
doleaks and endotension: summary of opinions expressed at an 
international conference. J Vasc Surg. 2002;35:1029-35.
14. Mory M, Allenberg JR, Schumacher H, von Tengg-Kobligk H, 
Böckler D. Open decompression, proximal banding, and aneurysm 
sac fenestration as an alternative to conversion in the manage-
ment of endotension after EVAR. J Endovasc Ther. 2008;15:449-52.
15. Goodney PP, Fillinger MF. The effect of endograft relining on sac 
expansion after endovascular aneurysm repair with the original-
permeability Gore Excluder abdominal aortic aneurysm endo-
prosthesis. J Vasc Surg. 2007;45:686-93.
Correspondence:
Marcelo Bellini Dalio 
Departamento de Cirurgia e Anatomia, FMRP, USP 
Av. Bandeirantes, 3900, 90 andar, 
CEP 14048-900 – Ribeirão Preto, SP, Brazil 
Tel.: +55 16 3602.2406 
Fax: +55 16 3633.0836 
E-mail: mbdalio@gmail.com
Author contributions:
Conception and design: EEJ 
Analysis and interpretation: EEJ, MBD 
Data collection: JGCJ 
Writing the article: MBD, EEJ, 
Critical revision of the article: CEP, TM, NRAD 
Final approval of the article*: MBD 
Statistcal analysis: N/A 
Overall responsability: MBD 
Obtained fouding: N/A 
* All authors have read and approved the final version of the article submitted 
to J Vasc Bras.


Tratamento endovascular da endotensão com endoprótese de dácron e derivação femoro-femoral cruzada: desafio terapêutico

RCAAP - Repositório Científico de Acesso Aberto de Portugal

Tratamento endovascular da endotensão com endoprótese de dácron e derivação femoro-femoral cruzada: desafio terapêutico

Abstract

Similar works

Full text

Available Versions

Directory of Open Access Journals

Biblioteca Digital da Produção Intelectual da Universidade de São Paulo (BDPI/USP)

RCAAP - Repositório Científico de Acesso Aberto de Portugal