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Incidence And Management Of Type IIIb Endoleaks Affecting The Main Aortic Component After Fenestrated-branched Endovascular Aortic Repair Of Complex Aortic Aneurysms
Lucas Ruiter Kanamori, MD
1, Regina Husman, MD
1, Andres Figueroa, MD
2, Bruno P. Schmid, MD
1, Dora Babocs, MD
1, Priscila Suguita, MD
1, Natalia Coronel, MD
2, Marilisa Soto, MD
2, Guilherme BB Lima, MD, PhD
3, Ying Huang, MD, PhD
1, Steven Maximus, MD
1, Bernardo C. Mendes, MD
4, Thanila A. Macedo, MD
1, Laura Ocasio, MD
1, Sukgu M. Han, MD
5, Carlos Timaran, MD
2, Gustavo S. Oderich, MD
1.
1Advanced Aortic Research Program, Departments of Cardiothoracic & Vascular Surgery and Diagnostic Imaging and Interventional Radiology, McGovern Medical School, University of Texas Health Houston, Houston, TX, USA,
2Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA,
3Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA,
4Division of Vascular and Endovascular Surgery, Mayo Clinic, Richester, MN, USA,
5Comprehensive Aortic Center, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA.
OBJECTIVE:
Type IIIB endoleak (T3bE) due to fabric tears or integrity issues are infrequent, but have been poorly described among patients undergoing fenestrated-branched endovascular aortic repair (FB-EVAR). The aim of this study is to describe the incidence, management and outcomes of T3bEs following FB-EVAR for treatment of complex abdominal (CAAA) and thoracoabdominal aortic aneurysms (TAAAs).
METHODS:
The clinical data, imaging and outcomes of consecutive patients enrolled in prospective non-randomized physician-sponsored investigational device exemption studies to evaluate manufactured devices for FB-EVAR at two centers was reviewed between 2013-2024. Patients with unequivocal T3bE affecting the main aortic fenestrated-branched device component and confirmed by contrast-enhanced ultrasound (CEUS), dynamic CTA and/or angiography were included. Endpoints were the cumulative incidence of T3bE, treatment approaches, mortality, major adverse events, secondary interventions and aneurysm rupture.
RESULTS:
There were 717 patients (72% male; mean age, 74±8 years-old) were treated by FB-EVAR for CAAA and TAAAs. After a median follow up of 33 years (IQR, 13 to 53), seven patients (0.9%) had unequivocal diagnosis of T3bE affecting the main component of a fenestrated-branched device (
Figure 1A). Cumulative incidence of T3bE at 3- and 5-years was 0.9% (95% CI 0.0-1.8%) and 2.2% (95% CI 0.4-4.0%), respectively. All patients had prior imaging showing no endoleak, were asymptomatic and were identified by surveillance imaging with final diagnosis established by CEUS in two, dynamic CTA in one and angiography in four. Of the seven patients, six underwent endovascular repair with redo fenestrated-branch device in three, parallel stent, cuff extension or endovascular plug/coils in one each (
Figure 1B). Five secondary interventions successfully eradicated the T3bE with one patient presenting an aortic-related mortality secondary to aneurysm rupture. One patient was managed conservatively with clinical surveillance had spontaneous resolution of the endoleak.
CONCLUSIONS:
Type IIIb endoleak from fabric tears or integrity issue are uncommon after FB-EVAR, but may pose diagnostic and treatment challenge if the affected segment involves fenestrations and directional branches. Redo treatment is effective in selected patients. Persistent leaks may lead to sac expansion and rupture.
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