Back to 2016 Annual Symposium Abstacts

OBJECTIVES:
Snorkel/chimney (Sn-EVAR) endografts have gained in popularity to address the lack of widespread availability and manufacturing limitations of branched/fenestrated devices in the treatment of complex AAAs. Despite high technical success and mid-term patency of snorkel-stent configurations, concerns remain regarding the high incidence of perceived early type IA gutter endoleaks due to lack of circumferential seal. We sought to evaluate the incidence and natural history of gutter endoleaks following Sn-EVAR.

METHODS:
Review of medical records and available imaging studies, including completion angiography and serial CT-A, was performed for all patients undergoing Sn-EVAR at our institution between September 2009 and January 2015. Only procedures involving ≥1 renal artery with or without visceral snorkel stents were included. Need for secondary intervention related to treatment of gutter endoleaks was also recorded.

RESULTS: Sixty patients (mean age, 75.3 ± 7.6 years; male, 70.0%) underwent Sn-EVAR with a total of 108 snorkel stents (96 renal [36 bilateral], 10 SMA, 2 celiac). A median of 2 (range, 1-4) snorkel stents were placed per patient. Type 1A gutter endoleaks were noted on completion angiography in 35.0% of patients. Follow-up CT-A revealed spontaneous resolution of gutter endoleaks in 20.1%, 46.2%, 61.0%, and 80.4% of patients at one-month, six-months, one-year, and two-years post-procedure, respectively (Figure). Multivariate analysis revealed the presence of ≥2 snorkel stents to be protective (OR 0.17 [95% CI, 0.51-0.54], P=.003) from gutter endoleak development, whereas long-term anticoagulation, device oversizing, stent diameter, and other clinical/anatomic variables were not significantly predictive of gutter endoleaks. One patient (1.7%) required secondary intervention related to a persistent gutter endoleak. At mean radiologic follow-up of 16.4 months, no difference in mean aneurysm sac size change was observed between those with or without early gutter endoleaks (-6.2mm vs. -5.3mm, P=NS).

CONCLUSIONS: Type IA gutter endoleaks represent a relatively frequent early occurrence following Sn-EVAR but appears to resolve spontaneously in the majority of cases. Given that few patients require intervention related to gutter endoleaks and the presence of such endoleak does not necessarily correlate to increased risk for aneurysm sac growth, the natural history of gutter endoleaks may be more benign than originally feared.