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Robotic Assisted Laparoscopic Approach To Lumbar Artery And Inferior Mesenteric Artery Ligation For Treatment Of Type 2 Endoleak
Charudatta Bavare, MD, Jacob Basil Watson, MD, Rahul Ghosh, BS, Matthew Kenny, B.S., Alan Lumsden, MD.
Houston Methodist Hospital, Houston, TX, USA.
Introduction: Endoleaks, reportedly occur in 20-40% of patients receiving Endovascular Aneurysm Repair (EVAR) remaining the most common complication after EVAR.
1,2 Type-2 endoleaks are the most common type of endoleak. Many remain asymptomatic, can be surveilled, and do not require intervention, but if residual aneurysm sac growth >5mm or if the patient becomes symptomatic, these patients are considered for re-intervention. Many approaches are described to treat type-2 endoleaks. Commonly described approaches are endovascular via collateral pathways utilizing coils or onyx, translumbar, transcaval, and transgraft. When endovascular approaches fail, the next choice traditionally has been open laparotomy to ligate feeding vessels from multiple locations. Few case reports exist describing robotic-assisted laparoscopic ligation of the IMA
5-7, but robotic-assisted laparoscopic (RAL) ligation of lumbar arteries has not been described. This video describes operative planning and surgical techniques for RAL lumbar artery and IMA ligation for type 2 endoleak.
Methods This report details the case of an 85-year-old male who initially underwent EVAR for 7.2cm AAA with initial surveillance imaging at 3 months showing sac regression to 6.5cm. He was lost to follow up and presented 6 years later with asymptomatic 7.8cm AAA and evidence of type 2 endoleak originating from IMA and 3 lumbar arteries (L3-L5 level). He underwent a RAL ligation of the IMA and 3 lumbar arteries.
Results Successful ligation of IMA and 3 lumbar arteries (L3-L5). Procedure duration was 153 minutes and estimated blood loss was 25 mL. The hospital length of stay was 2 days. There were no intra-operative or post-operative complications. The patient was discharged home in healthy condition.
Conclusions RAL ligation of IMA and lumbar arteries can be safely performed and is a promising option for patients with type-2 endoleaks from multiple source vessels or in patients who fail prior endovascular therapy and would otherwise undergo open repair.
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