617295
research-article2015
JETXXX10.1177/1526602815617295Journal of Endovascular TherapyPanoulas et al
Case Report
Transarterial Endoleak Closure After Endovascular Thoracoabdominal Aneurysm Repair: When the “Sandwich” Goes Wrong
Journal of Endovascular Therapy 2016, Vol. 23(1) 220–224 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602815617295 www.jevt.org
Vasileios F. Panoulas, MD, MRCP, PhD1,2,3, Matteo Montorfano, MD1, Azeem Latib, MD1,2, Gennaro Giustino, MD1, Pietro Spagnolo, MD4, Maurizio Taramasso, MD1, Alaide Chieffo, MD1, Efrem Civilini, MD5, Roberto Chiesa, MD, PhD5, and Antonio Colombo, MD1,2
Abstract Purpose: To describe the use of vascular plugs to close a complex type Ib endoleak following the sandwich procedure used in conjunction with endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Case Report: A 59-year-old man with a 6.5-mm TAAA was treated with initial deployment proximally of 2 Zenith TX2 stent-grafts. In preparation for the sandwich technique to preserve flow to the celiac trunk, a 10×100-mm Viabahn covered stent was delivered from a brachial access into the celiac trunk unprotected by the sheath of the introducer. The trigger wire system became snagged on the struts of the distal aortic stent-graft; when the wire was pulled, the proximal end of the Viabahn migrated outside the aortic stent-graft, which migrated upward. The main body extension intended for the aortic component of the sandwich technique was deployed close to the distal end of the aneurysm sac, but a large type Ib endoleak formed in the gutter between the Viabahn, aortic extension, and sac wall. The leak perfused the celiac trunk, and the procedure was terminated. Increasing sac size on 3-month imaging prompted closure of the leak with 2 type II Amplatzer vascular plugs aiming to occlude the endoleak outflow into the Viabahn and the endoleak outflow at the site of the gutter. Imaging followup at 6 months demonstrated successful exclusion of the TAAA with no residual endoleak and excellent perfusion of the celiac trunk. Conclusion: Transarterial treatment of complex endoleaks is feasible when preceded by meticulous imaging and detailed preprocedural planning. Keywords celiac trunk, complication, endoleak, gutter, migration, sandwich technique, stent-graft, thoracoabdominal aortic aneurysm, vascular plug
Introduction Thoracoabdominal aortic aneurysms (TAAAs) are relatively uncommon in the spectrum of aneurysmal disease, accounting for only 3% of diagnosed aneurysms in the United States. There are currently 5 types of TAAAs that describe the extent of involvement in relation to anatomic landmarks (subclavian artery, sixth intercostal space, diaphragm, renal arteries, and iliac bifurcation).1 Criteria guiding the timing of TAAA intervention were published in 2009.2 Indications include absolute size (>6.5 cm), rapid growth, symptoms, acute dissection, or rupture. Standard thoracic endovascular repair alone is not currently considered an adequate approach to treat TAAA because of the visceral arteries involved in the aneurysm sac, so the “sandwich technique” was developed.3 In a case
series by Lobato and Camacho-Lobato,3 half of the patients treated with the sandwich tenchique developed endoleaks of various types, half of which required surgical or endovascular intervention. We describe transarterial closure of a 1
Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy EMO-GVM Centro Cuore Columbus, Milan, Italy 3 Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, UK 4 CPC-Cardiovascular Protection Center, San Raffaele Scientific Institute, Milan, Italy 5 Vascular Surgery Unit, San Raffaele Scientific Institute, Milan, Italy 2
Corresponding Author: Antonio Colombo, EMO-GVM Centro Cuore Columbus, 48 Via M. Buonarroti, 20145 Milan, Italy. Email: [email protected]
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Figure 1. Computed tomography (CT) findings in coronal (A′, B′, C′) and 3-dimensional reconstruction (A, B, C). (A, A′) Thoracoabdominal aneurysm. (B, B′) Type Ib endoleak through a neck/gutter created between the Viabahn covered stent, the aortic stent-graft, and the aneurysm wall. (C, C′) CT 1 month after using 2 Amplatzer vascular plugs to close the endoleak; note the isolation and thrombosis of the aneurysm.
type Ib endoleak after an unsuccessful endovascular repair of a TAAA.
Case Report A 59-year-old smoker with arterial hypertension and dyslipidemia presented with a 6.5-mm TAAA (Figure 1A and 1A′), which was treated with an endovascular repair. After initial deployment proximally of 2 Zenith TX2 stentgrafts (30×140 mm and 36×127 mm; Cook Medical, Bloomington, IN, USA), the operators opted to preserve celiac trunk perfusion with the sandwich technique and a Viabahn covered stent (W.L. Gore & Associates, Inc, Flagstaff, AZ, USA). The 10×100-mm Viabahn was delivered from a brachial access into the celiac axis; however, the trigger wire used to deploy the Viabahn became
trapped on the distal struts of the second aortic stent-graft; when the wire was pulled, the proximal end of the Viabahn migrated outside the aortic stent-graft as the distal stentgraft migrated upward. We speculated that the reason for this unpredictable and, once started, unavoidable movement was related to the insertion of the Viabahn unprotected by the sheath of the introducer. After migration of the Viabahn into the aneurysm sac, guidewire access from above was lost, and the operators opted to continue sealing the distal end of the aneurysm, deploying the Zenith 36×77-mm main body extension (Figure 1B and 1B′). The proximal end of the Viabahn was squeezed in between the aortic stent-graft and the aneurysm wall, creating a gutter and a type Ib endoleak. The celiac trunk was supplied by blood from the aorta flowing through the gutter of the endoleak, into the sac,
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Figure 2. Anatomical relation between the aneurysm sac, aortic stent-grafts, and the Viabahn prosthesis. (A) Three-dimensional computed tomography (CT) reconstruction showing the posterior view of the endoleak. (B) Contrast-enhanced CT left posterior view of the type Ib endoleak. (C) Schematic presentation of B: blood flow through the endoleak between the Viabahn and the aortic wall (orange circle) into the sac, exiting through the Viabahn (blue) into the celiac trunk. Red arrows indicate systemic blood flow.
and then antegrade through the Viabahn into the celiac trunk (Figure 2). Computed tomography angiography (CTA) showed the aortic stent-grafts implanted at the thoracoabdominal region, with a Viabahn covered stent extending from the ostium of the celiac trunk across the aorta (at the distal edge of the Zenith extension) to the space defined between the right posterolateral aneurysm sac wall and the exterior surface of the Zenith extension (Figures 1B, 1B′, and 2). Initially, a conservative approach was chosen; however, CTA at 3-month follow-up demonstrated an increase in the aneurysm diameter from 6.5 to 7 cm. The multidisciplinary team opted for a plan to percutaneously close the endoleak while maintaining celiac trunk perfusion. Using a transfemoral approach, the Viabahn was perforated using a Brockenbrough needle (Figure 3). An Asahi Miraclebros 3 coronary wire (Abbott Vascular, Santa Clara, CA, USA) that had 20 mm from its distal floppy end removed was advanced into the aneurysm sac. Using an over-the-wire balloon, the Miraclebros 3 was exchanged for a Hi-Torque Iron Man guidewire (Abbott Vascular). After several dilations of the Viabahn covered stent with semi- and noncompliant coronary balloons, a Storq wire (Cordis Corporation, Bridgewater, NJ, USA) was advanced into the aneurysm sac. An 8-mm peripheral balloon was advanced over the Storq wire through the opening created at the caudal side of the Viabahn and
inflated to 8 atm. This maneuver facilitated perfusion of the celiac trunk directly from the aorta and provided access to the proximal end of the Viabahn (facing the aneurysm sac) for delivery of an Amplatzer Type II Vascular Plug (St. Jude Medical, St. Paul, MN, USA) to occlude the outflow from the endoleak into the Viabahn. The Storq wire was subsequently repositioned distally in the celiac trunk, and a self-expanding 12×40-mm Absolute stent (Abbott Vascular) was deployed to maintain the caudal opening of the Viabahn. Subsequently, another Amplatzer Vascular Plug II was deployed at the gutter of the endoleak (at the side of the Viabahn) after crossing it with the Storq wire. At the end of the procedure, control angiography revealed only minor residual type Ib endoleak, while good perfusion of the celiac trunk was established through the caudal opening of the Viabahn (Figures 1C, 1C′, and 4). CTA follow-up at 6 months (Figure 5) demonstrated successful exclusion of the TAAA with no residual endoleak and excellent perfusion of the celiac trunk.
Discussion The sandwich technique for TAAA repair appears to be a safe, well-tolerated, feasible alternative using off-theshelf stent-grafts to provide efficient visceral revascularization.3 Postprocedural endoleaks, however, are not an
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Figure 3. Step-by-step percutaneous type Ib endoleak closure with simultaneous restoration of celiac trunk perfusion. (A) The Viabahn (blue arrow) was perforated using a Brockenbrough needle (yellow arrow). After several dilations of the Viabahn covered stent with semi- and noncompliant coronary balloons, (B) a Storq wire was advanced into the sac for delivery of an 8-mm peripheral balloon through the opening created at the caudal side of the Viabahn. The balloon was inflated to 8 atm. (C) An Amplatzer type II vascular plug (yellow arrow) was deployed successfully through the delivery sheath (blue arrow), (D) thus occluding the outflow from the endoleak. (E) The Storq wire (blue arrow) was repositioned distally in the celiac trunk, and a 12×40-mm Absolute stent (yellow arrow) was deployed to maintain the caudal opening of the Viabahn. (F) After postdilation of the Absolute stent with an 8-mm balloon (blue arrow), the neck/gutter of the endoleak was crossed with a Storq wire. (G) Angiographic control revealed that the wire was through the gutter (at the side of the Viabahn). (H) Another Amplatzer vascular plug II (yellow arrow) was deployed in the gutter. The blue arrow in H indicates the previous Amplatzer within the Viabahn. At the end of the procedure, (I) control angiography revealed a small low-flow residual type Ib endoleak, while good perfusion of the celiac trunk was established through the caudal opening of the Viabahn (yellow arrow).
uncommon encounter, and there are limited data on their management. In the study by Lobato and CamachoLobato,3 7 endoleaks (1 type I, 3 type II, 1 type III, and 2 type IV) were detected in 15 sandwich procedures; some were treated with further endovascular procedures and some sealed on their own after “watchful waiting.” In another study from Germany, Schwierz et al4 treated 32 TAAAs with the sandwich technique. A third of patients were noted to have endoleaks on the 1-week CT (5 type I, 4 type II, and 8 type III). Patients with major filling of the aneurysm sac on intraoperative angiography were classified as a high-flow type I or III leak and treated with coils. One patient with a type I endoleak was treated with a proximal extension.
One of the major caveats of any “chimney-based” procedure, whether complicated or not, is the creation of gutters, which can prevent immediate sealing and exclusion of the aneurysm. Leaks from these gutters should be distinguished into high flow vs low flow.5 Even though the latter appear to seal over time,4 a more aggressive approach should be adopted for the high-flow endoleaks. This could involve either further endovascular procedures, intraoperative coil deployment, or as in our case, the use of vascular plugs where feasible.
Conclusion Percutaneous closure of a complex type Ib endoleak following the sandwich procedure during TAAA repair can be
224
Journal of Endovascular Therapy 23(1)
Figure 4. (A1, B1) Before and (A2, B2) after percutaneous endoleak closure with 2 Amplatzer vascular plugs II. B1 demonstrates clearly the entry-gutter to the aneurysm (yellow arrow) and its outflow (blue arrow) through the Viabahn to the celiac trunk.
accomplished with vascular plugs in selected cases such as the one detailed in this report. Percutaneous treatment of complex endoleaks is feasible when preceded by meticulous imaging and detailed preprocedural planning. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
Figure 5. Six-month computed tomography reveals an excluded, thrombosed aneurysm (yellow arrows). The red arrow indicates the location of the 2 Amplatzer vascular plugs II and the blue arrow points to the Absolute stent through which the celiac trunk is perfused.
1. Safi HJ, Miller CC III. Spinal cord protection in descending thoracic and thoracoabdominal aortic repair. Ann Thorac Surg. 1999;67:1937–1979. 2. Elefteriades JA, Botta DM Jr. Indications for the treatment of thoracic aortic aneurysms. Surg Clin North Am. 2009;89:845–867, ix. 3. Lobato AC, Camacho-Lobato L. A new technique to enhance endovascular thoracoabdominal aortic aneurysm therapy—the sandwich procedure. Semin Vasc Surg. 2012; 25:153–160. 4. Schwierz E, Kolvenbach RR, Yoshida R, et al. Experience with the sandwich technique in endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2014;59:1562–1569. 5. Lachat M, Bisdas T, Rancic Z, et al. Chimney endografting for pararenal aortic pathologies using transfemoral access and the lift technique. J Endovasc Ther. 2013;20:492–497.
research-article2015
JETXXX10.1177/1526602815617295Journal of Endovascular TherapyPanoulas et al
Case Report
Transarterial Endoleak Closure After Endovascular Thoracoabdominal Aneurysm Repair: When the “Sandwich” Goes Wrong
Journal of Endovascular Therapy 2016, Vol. 23(1) 220–224 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602815617295 www.jevt.org
Vasileios F. Panoulas, MD, MRCP, PhD1,2,3, Matteo Montorfano, MD1, Azeem Latib, MD1,2, Gennaro Giustino, MD1, Pietro Spagnolo, MD4, Maurizio Taramasso, MD1, Alaide Chieffo, MD1, Efrem Civilini, MD5, Roberto Chiesa, MD, PhD5, and Antonio Colombo, MD1,2
Abstract Purpose: To describe the use of vascular plugs to close a complex type Ib endoleak following the sandwich procedure used in conjunction with endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Case Report: A 59-year-old man with a 6.5-mm TAAA was treated with initial deployment proximally of 2 Zenith TX2 stent-grafts. In preparation for the sandwich technique to preserve flow to the celiac trunk, a 10×100-mm Viabahn covered stent was delivered from a brachial access into the celiac trunk unprotected by the sheath of the introducer. The trigger wire system became snagged on the struts of the distal aortic stent-graft; when the wire was pulled, the proximal end of the Viabahn migrated outside the aortic stent-graft, which migrated upward. The main body extension intended for the aortic component of the sandwich technique was deployed close to the distal end of the aneurysm sac, but a large type Ib endoleak formed in the gutter between the Viabahn, aortic extension, and sac wall. The leak perfused the celiac trunk, and the procedure was terminated. Increasing sac size on 3-month imaging prompted closure of the leak with 2 type II Amplatzer vascular plugs aiming to occlude the endoleak outflow into the Viabahn and the endoleak outflow at the site of the gutter. Imaging followup at 6 months demonstrated successful exclusion of the TAAA with no residual endoleak and excellent perfusion of the celiac trunk. Conclusion: Transarterial treatment of complex endoleaks is feasible when preceded by meticulous imaging and detailed preprocedural planning. Keywords celiac trunk, complication, endoleak, gutter, migration, sandwich technique, stent-graft, thoracoabdominal aortic aneurysm, vascular plug
Introduction Thoracoabdominal aortic aneurysms (TAAAs) are relatively uncommon in the spectrum of aneurysmal disease, accounting for only 3% of diagnosed aneurysms in the United States. There are currently 5 types of TAAAs that describe the extent of involvement in relation to anatomic landmarks (subclavian artery, sixth intercostal space, diaphragm, renal arteries, and iliac bifurcation).1 Criteria guiding the timing of TAAA intervention were published in 2009.2 Indications include absolute size (>6.5 cm), rapid growth, symptoms, acute dissection, or rupture. Standard thoracic endovascular repair alone is not currently considered an adequate approach to treat TAAA because of the visceral arteries involved in the aneurysm sac, so the “sandwich technique” was developed.3 In a case
series by Lobato and Camacho-Lobato,3 half of the patients treated with the sandwich tenchique developed endoleaks of various types, half of which required surgical or endovascular intervention. We describe transarterial closure of a 1
Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy EMO-GVM Centro Cuore Columbus, Milan, Italy 3 Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, UK 4 CPC-Cardiovascular Protection Center, San Raffaele Scientific Institute, Milan, Italy 5 Vascular Surgery Unit, San Raffaele Scientific Institute, Milan, Italy 2
Corresponding Author: Antonio Colombo, EMO-GVM Centro Cuore Columbus, 48 Via M. Buonarroti, 20145 Milan, Italy. Email: [email protected]
Panoulas et al
221
Figure 1. Computed tomography (CT) findings in coronal (A′, B′, C′) and 3-dimensional reconstruction (A, B, C). (A, A′) Thoracoabdominal aneurysm. (B, B′) Type Ib endoleak through a neck/gutter created between the Viabahn covered stent, the aortic stent-graft, and the aneurysm wall. (C, C′) CT 1 month after using 2 Amplatzer vascular plugs to close the endoleak; note the isolation and thrombosis of the aneurysm.
type Ib endoleak after an unsuccessful endovascular repair of a TAAA.
Case Report A 59-year-old smoker with arterial hypertension and dyslipidemia presented with a 6.5-mm TAAA (Figure 1A and 1A′), which was treated with an endovascular repair. After initial deployment proximally of 2 Zenith TX2 stentgrafts (30×140 mm and 36×127 mm; Cook Medical, Bloomington, IN, USA), the operators opted to preserve celiac trunk perfusion with the sandwich technique and a Viabahn covered stent (W.L. Gore & Associates, Inc, Flagstaff, AZ, USA). The 10×100-mm Viabahn was delivered from a brachial access into the celiac axis; however, the trigger wire used to deploy the Viabahn became
trapped on the distal struts of the second aortic stent-graft; when the wire was pulled, the proximal end of the Viabahn migrated outside the aortic stent-graft as the distal stentgraft migrated upward. We speculated that the reason for this unpredictable and, once started, unavoidable movement was related to the insertion of the Viabahn unprotected by the sheath of the introducer. After migration of the Viabahn into the aneurysm sac, guidewire access from above was lost, and the operators opted to continue sealing the distal end of the aneurysm, deploying the Zenith 36×77-mm main body extension (Figure 1B and 1B′). The proximal end of the Viabahn was squeezed in between the aortic stent-graft and the aneurysm wall, creating a gutter and a type Ib endoleak. The celiac trunk was supplied by blood from the aorta flowing through the gutter of the endoleak, into the sac,
222
Journal of Endovascular Therapy 23(1)
Figure 2. Anatomical relation between the aneurysm sac, aortic stent-grafts, and the Viabahn prosthesis. (A) Three-dimensional computed tomography (CT) reconstruction showing the posterior view of the endoleak. (B) Contrast-enhanced CT left posterior view of the type Ib endoleak. (C) Schematic presentation of B: blood flow through the endoleak between the Viabahn and the aortic wall (orange circle) into the sac, exiting through the Viabahn (blue) into the celiac trunk. Red arrows indicate systemic blood flow.
and then antegrade through the Viabahn into the celiac trunk (Figure 2). Computed tomography angiography (CTA) showed the aortic stent-grafts implanted at the thoracoabdominal region, with a Viabahn covered stent extending from the ostium of the celiac trunk across the aorta (at the distal edge of the Zenith extension) to the space defined between the right posterolateral aneurysm sac wall and the exterior surface of the Zenith extension (Figures 1B, 1B′, and 2). Initially, a conservative approach was chosen; however, CTA at 3-month follow-up demonstrated an increase in the aneurysm diameter from 6.5 to 7 cm. The multidisciplinary team opted for a plan to percutaneously close the endoleak while maintaining celiac trunk perfusion. Using a transfemoral approach, the Viabahn was perforated using a Brockenbrough needle (Figure 3). An Asahi Miraclebros 3 coronary wire (Abbott Vascular, Santa Clara, CA, USA) that had 20 mm from its distal floppy end removed was advanced into the aneurysm sac. Using an over-the-wire balloon, the Miraclebros 3 was exchanged for a Hi-Torque Iron Man guidewire (Abbott Vascular). After several dilations of the Viabahn covered stent with semi- and noncompliant coronary balloons, a Storq wire (Cordis Corporation, Bridgewater, NJ, USA) was advanced into the aneurysm sac. An 8-mm peripheral balloon was advanced over the Storq wire through the opening created at the caudal side of the Viabahn and
inflated to 8 atm. This maneuver facilitated perfusion of the celiac trunk directly from the aorta and provided access to the proximal end of the Viabahn (facing the aneurysm sac) for delivery of an Amplatzer Type II Vascular Plug (St. Jude Medical, St. Paul, MN, USA) to occlude the outflow from the endoleak into the Viabahn. The Storq wire was subsequently repositioned distally in the celiac trunk, and a self-expanding 12×40-mm Absolute stent (Abbott Vascular) was deployed to maintain the caudal opening of the Viabahn. Subsequently, another Amplatzer Vascular Plug II was deployed at the gutter of the endoleak (at the side of the Viabahn) after crossing it with the Storq wire. At the end of the procedure, control angiography revealed only minor residual type Ib endoleak, while good perfusion of the celiac trunk was established through the caudal opening of the Viabahn (Figures 1C, 1C′, and 4). CTA follow-up at 6 months (Figure 5) demonstrated successful exclusion of the TAAA with no residual endoleak and excellent perfusion of the celiac trunk.
Discussion The sandwich technique for TAAA repair appears to be a safe, well-tolerated, feasible alternative using off-theshelf stent-grafts to provide efficient visceral revascularization.3 Postprocedural endoleaks, however, are not an
223
Panoulas et al
Figure 3. Step-by-step percutaneous type Ib endoleak closure with simultaneous restoration of celiac trunk perfusion. (A) The Viabahn (blue arrow) was perforated using a Brockenbrough needle (yellow arrow). After several dilations of the Viabahn covered stent with semi- and noncompliant coronary balloons, (B) a Storq wire was advanced into the sac for delivery of an 8-mm peripheral balloon through the opening created at the caudal side of the Viabahn. The balloon was inflated to 8 atm. (C) An Amplatzer type II vascular plug (yellow arrow) was deployed successfully through the delivery sheath (blue arrow), (D) thus occluding the outflow from the endoleak. (E) The Storq wire (blue arrow) was repositioned distally in the celiac trunk, and a 12×40-mm Absolute stent (yellow arrow) was deployed to maintain the caudal opening of the Viabahn. (F) After postdilation of the Absolute stent with an 8-mm balloon (blue arrow), the neck/gutter of the endoleak was crossed with a Storq wire. (G) Angiographic control revealed that the wire was through the gutter (at the side of the Viabahn). (H) Another Amplatzer vascular plug II (yellow arrow) was deployed in the gutter. The blue arrow in H indicates the previous Amplatzer within the Viabahn. At the end of the procedure, (I) control angiography revealed a small low-flow residual type Ib endoleak, while good perfusion of the celiac trunk was established through the caudal opening of the Viabahn (yellow arrow).
uncommon encounter, and there are limited data on their management. In the study by Lobato and CamachoLobato,3 7 endoleaks (1 type I, 3 type II, 1 type III, and 2 type IV) were detected in 15 sandwich procedures; some were treated with further endovascular procedures and some sealed on their own after “watchful waiting.” In another study from Germany, Schwierz et al4 treated 32 TAAAs with the sandwich technique. A third of patients were noted to have endoleaks on the 1-week CT (5 type I, 4 type II, and 8 type III). Patients with major filling of the aneurysm sac on intraoperative angiography were classified as a high-flow type I or III leak and treated with coils. One patient with a type I endoleak was treated with a proximal extension.
One of the major caveats of any “chimney-based” procedure, whether complicated or not, is the creation of gutters, which can prevent immediate sealing and exclusion of the aneurysm. Leaks from these gutters should be distinguished into high flow vs low flow.5 Even though the latter appear to seal over time,4 a more aggressive approach should be adopted for the high-flow endoleaks. This could involve either further endovascular procedures, intraoperative coil deployment, or as in our case, the use of vascular plugs where feasible.
Conclusion Percutaneous closure of a complex type Ib endoleak following the sandwich procedure during TAAA repair can be
224
Journal of Endovascular Therapy 23(1)
Figure 4. (A1, B1) Before and (A2, B2) after percutaneous endoleak closure with 2 Amplatzer vascular plugs II. B1 demonstrates clearly the entry-gutter to the aneurysm (yellow arrow) and its outflow (blue arrow) through the Viabahn to the celiac trunk.
accomplished with vascular plugs in selected cases such as the one detailed in this report. Percutaneous treatment of complex endoleaks is feasible when preceded by meticulous imaging and detailed preprocedural planning. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
Figure 5. Six-month computed tomography reveals an excluded, thrombosed aneurysm (yellow arrows). The red arrow indicates the location of the 2 Amplatzer vascular plugs II and the blue arrow points to the Absolute stent through which the celiac trunk is perfused.
1. Safi HJ, Miller CC III. Spinal cord protection in descending thoracic and thoracoabdominal aortic repair. Ann Thorac Surg. 1999;67:1937–1979. 2. Elefteriades JA, Botta DM Jr. Indications for the treatment of thoracic aortic aneurysms. Surg Clin North Am. 2009;89:845–867, ix. 3. Lobato AC, Camacho-Lobato L. A new technique to enhance endovascular thoracoabdominal aortic aneurysm therapy—the sandwich procedure. Semin Vasc Surg. 2012; 25:153–160. 4. Schwierz E, Kolvenbach RR, Yoshida R, et al. Experience with the sandwich technique in endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2014;59:1562–1569. 5. Lachat M, Bisdas T, Rancic Z, et al. Chimney endografting for pararenal aortic pathologies using transfemoral access and the lift technique. J Endovasc Ther. 2013;20:492–497.
