Banding for type IA endoleak after endovascular abdominal aortic repair: An underexposed treatment option

Introduction

Over the past two decades endovascular aneurysm repair (EVAR) has emerged as an established treatment for abdominal aortic aneurysms (AAAs). ¹ More and more challenging AAAs with unfavorable proximal aortic neck anatomy are treated with endovascular means. ² As a consequence, proximal inadequate sealing may result in IA endoleak, which in turn can lead to AAA progression or rupture. The presence of type IA endoleak is an indication for secondary interventions, each associated with its own success rate and procedure-related morbidity and mortality. Proximal revision with use of fenestrated devices can be time consuming and expensive. Extender cuffs in combination with Chimney grafts for reno-visceral arteries demand catheterization of the supra-aortic arteries. ³ Moreover, the use of EndoAnchors will not be successful when the gap between endograft and arterial wall is >2 mm.^4,5

Despite revision surgery, residual or recurrent type IA endoleaks due to complex anatomy or short, calcified aortic necks is not an exception. External aortic banding can be a good option to solve a type IA endoleak, but is underreported in literature; we present two cases and review literature.

Methods – surgical technique

All interventions were performed in a hybrid endovascular suite. First, an endovascular procedure was performed, to deploy a juxtarenal stent that functions as a robust cage. The stents that were used are reported for each case below. Second, upper-midline laparotomy incision was done. The retroperitoneal space was opened and the infrarenal aorta was exposed circumferentially. A Dacron prosthesis was cut and wrapped around the infrarenal aortic neck. The Dacron graft was tightly fixed with four clamps (Figure 1a and b.) Under these clamps, a Satinsky clamp was placed. Consequently, the band was sutured to the aorta and endograft with non-absorbable sutures under the Satinsky clamp to prevent future migration. Thereafter, an angiogram was performed to examine eventual residual endoleak (Figure 2). OPEN IN VIEWER

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Figure 2.

Angiogram after banding, showing no signs of persistent endoleak.

Cases

An 84-year-old female was referred to our hospital with a persisting type IA and type II endoleak after primary EVAR procedure with an Endurant stentgraft (Medtronic, Santa Rosa, CA, USA) in 2009. The diameter of the aneurysm was 59 mm. First, endovascular revision was performed by fixation of the Endurant endograft with EndoAnchors (Heli-FX Aortic Securement System, Aptus Endosystems, Sunnyvale, CA) combined with a proximal extension cuff that was also secured with EndoAnchors. Additional Xperguide puncture of the aneurysmal sac was performed to treat the type II endoleak, originating from two lumbar arteries and the inferior mesenteric artery. The aneurysmal sac was filled with two component fibrin glue (Tissucol, Baxter, Deerfield, Illinois, USA) and the origins of the arteries were embolized. Due to persisting type Ia endoleak an additional uncovered stent had to be placed in the juxtarenal aorta. A 36-24-36 × 130 mm JOTEC E-XL endoluminal aortic stent (Jotec, AG, Muri, Switzerland) was deployed.

Despite these interventions, a persisting type IA endoleak was seen after 28 days, with an increasing diameter of the aneurysm to 75 mm. Subsequently, proximal banding was performed through laparotomy. Final angiogram showed no signs of residual endoleak. The post-operative period was uneventful. At 1 and 2 years CTA no signs of endoleak or aneurysm growth were observed.

The second patient was referred to our hospital with a type IA endoleak and growth of the aneurysmal sac after aorto-uni-iliac endografting (Zenith Cook, Bloomington, IN, USA), femoro-femoral crossover bypass, and placement of an occluder in the left common iliac artery. The diameter was 68 mm. Due to the configuration of the infrarenal neck (severe suprarenal and infrarenal angulation), calcified juxtarenal aorta, and the small diameter of the renal arteries, this type IA endoleak could not be treated endovascularly by means of a fenestrated cuff or chimney procedure. Because of a gap >2 mm between the proximal endograft and the aortic neck at >50% of the circumference, EndoAnchors were not indicated.

Via groin access a cobalt chromium AndraStent XL® 20 × 39 mm (Andramed, Reutlingen, Germany) was deployed in the juxta- or transrenal aorta. Half of the stent covered the primary endograft, the proximal half was positioned transrenally. Immediately after stent placement, external banding of the infrarenal aorta was performed through laparotomy in a similar way like the aforementioned patient. Final angiogram and postoperative CTA showed no signs of residual type IA endoleak.

Discussion

Type IA endoleaks post-EVAR can be hard to solve endovascularly, especially in hostile aorta necks. Open surgical repair, (partial) endograft explantation, and potential re-implantation of renal arteries have been associated with a high risk of peri-operative morbidity and mortality. Advances of banding include the relatively short duration of surgery and no need for (suprarenal) aortic clamping, thereby avoiding visceral and renal ischemia. A few steps are essential for success of the banding procedure. It is important to realize that this is a two-step procedure, consisting of: I) endovascular stent placement, and II) surgical external aortic banding. To prevent distal migration or collapse of the endovascular graft during firm tightening of the external band, it is essential to first perform endovascular placement of an uncovered high radial forced balloon expanded stent with or without suprarenal fixation, which functions as a cage. Caution is warranted in patients with thrombus in the infrarenal aorta, because banding could dislodge the thrombus into the renal arteries. To prevent slipping and migration of the infrarenal band as well to prevent future migration of the endograft it is essential to suture the external band to the aorta and endograft with non-absorbable sutures. A method to determine whether the banding is tight enough to stop the endoleak is to monitor arterial pressure in the aneurysm sac. The external band is tight enough if the arterial pressure curve in the aneurysm sac flattens. Although banding is less invasive in comparison with total graft revision, laparotomy is still required with its own possible complications.^5,6 Laparoscopic banding may be performed, but needs special skills and expertise of the surgical team. Other new possibilities include laparoscopic suturing after Palmaz stenting. ⁷

Conclusion

External aortic banding is safe and effective to overcome type IA endoleaks when other minimal invasive treatments fail. Placement of a giant bare metal stent before banding acts like a cage and avoids infolding and migration of the endograft.