59  y.o . man: acute back pain
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59 y.o . man: acute back pain

11/7/15 CTA: AAA 6cm, with leak and retroperitoneal hematoma. 11/9/15 CTA: 2D . s/p. . Endologix. stent-graft repair: short bifurcated body, two proximal sleeves. 1. EVAR Endoleaks – RAML 1.31.17.

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59 y.o . man: acute back pain




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Presentation on theme: "59 y.o . man: acute back pain"— Presentation transcript:

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59 y.o. man: acute back pain

11/7/15 CTA: AAA 6cm, with leak and retroperitoneal hematoma11/9/15 CTA: 2D s/p Endologix stent-graft repair: short bifurcated body, two proximal sleeves

1

EVAR Endoleaks – RAML 1.31.17

Leaking AAA

s/p

EVAR

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Surveillance missed. 13 mos. later: acute back pain

12/8/16 CTA: Type 3 endoleak and acute sac rupturemain body angulated in relation to and separated from proximal components

proximal components slipped distally into sac2

EVAR Endoleaks – RAML 1.31.17

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EVAR Endoleaks

EVAR stent-graftspurpose: exclude pressure from aneurysm sac, maintain distal flow.design: self-expanding stents outwardly press microporous fabric against atherosclerotic aortic and iliac walls, and sac thrombus. materials: push limits of stent and fabric thickness/strength vs. delivery size.procedure: unlike open graft, no opportunity to ligate or reimplant side branches (lumbar arteries, IMA).after aneurysm exclusion: sac thrombus matures, reconfigures, hemolyzes.

these principles provide the opportunities for failure (endoleaks) and the requirement for lifelong imaging surveillance.Endoleaks: classify them with imaging to understand their mechanism, and thus,

the urgency and type of repair.3

EVAR Endoleaks – RAML 1.31.17

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Endoleak Classification

Type 1: proximal or distal seals fail: high-pressure leak: URGENT REPAIR1-month post-op: limb attachment leak: Rx covered stent4

EVAR Endoleaks – RAML 1.31.17

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Endoleak Classification

Type 2: aortic side branches reconstitute flow in sac: lumbars, IMAlow-pressure leak: FOLLOW SAC SIZEembolize electively if leak persistent AND sac enlarging5

EVAR Endoleaks – RAML 1.31.17

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Endoleak Classification

Type 3: graft disruption: fabric tear, component separationhigh-pressure leak: URGENT REPAIR6

EVAR Endoleaks – RAML 1.31.17

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Endoleak Classification

Type 4: porous fabric: usually seen while still anticoagulated postop.low-pressure leak: await reversal of anticoagulation.Type 5: “endotension”: sac growth in the absence of a visible leak.low-pressure leak: re-line stent-graft electively if sac enlarging

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EVAR Endoleaks – RAML 1.31.17

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Summary

Endoleaks: classify them with imaging to understand their mechanism, and thus, the urgency and type of repair.High-pressure leaks: URGENT repair with covered stentsType 1: proximal or distal seals fail Type 3: graft disruption: fabric tear, component separation

Low-pressure leaks: treat electively if sac enlargingType 2: aortic side branches reconstitute flow in sac: lumbars, IMA

Type 4: porous fabric: usually seen while still anticoagulated postopType 5: “endotension”: sac growth in the absence of a visible leak8

EVAR Endoleaks – RAML 1.31.17

Radiology 2007;243:641-655. AJR 2009:192:W178-W186)

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