The Use of D-Stat Flowable Hemostat to Treat a Persistent Gutter Leak after Parallel Graft EVAR Treatment of a Symptomatic Thoracoabdominal Aneurysm
Roy W. Jones, MD, Mathew Wooster, MD, Murray Shames, MD.
University of South Florida, Tampa, FL, USA.
Introduction: A number of off-label techniques using parallel grafts have been proposed to treat thoracoabdominal aortic aneurysms with current EVAR devices. While technical success has reported for most of these procedures, the presence of gutter leaks and other endoleaks continues to compromise the success of the technique. We present the case of a combined Type II endoleak and gutter leak after a 3 vessel parallel graft procedure managed with celiac artery embolization and the use of D-StatŪ Flowable Hemostat. Methods: A 68 year old male patient was transferred to our facility with a symptomatic 6.4cm paravisceral AAA associated with flank and back pain. The patient was treated with ChEVAR using a Gore C3 endograft placed into the descending thoracic aorta. Three Viabahn bridging stents were then placed through the contralateral gate and extended into the SMA and both renal arteries. The ipsilateral limb was then extended with a second Gore C3 device and branched into the common iliac arteries. The celiac artery was intentionally covered since it had a high grade stenosis. Completion angiogram demonstrated a large Type II endoleak from the celiac artery. Delayed intervention was planned to embolize the celiac artery. CTA conducted on postoperative day 2 confirmed endoleak from the celiac origin in additional to a large gutter leak between the SMA and renal stents. Secondary intervention was performed to embolize the celiac artery via the SMA through a patent pancreaticoduodenal collateral. A large gutter leak remained prompting injection of flowable D-StatŪ directly into the aneurysm sac through a catheter placed through the gutter between the visceral stents and the contralateral gate. Rapid sac thromboses was visualized on angiography. Follow up CTA at 1 month demonstrated complete TAAA exclusion without any endoleak and patent branch stents without a visible gutter leak Conclusion: The use of D-StatŪ Flowable Hemostat in our case was a fast an effective treatment for persistent gutter leak and sac perfusion and adds to the armamentarium for treatment of this complication.
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