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Year : 2014  |  Volume : 1  |  Issue : 1  |  Page : 29-32

Management of Complex Type Iiia Endoleak by Brachio-femoral Realignment and Interposition Stent Graft and Review of the Literature

Department of Vascular Surgery, Narayana Institute of Vascular Sciences, Narayana Hrudaylaya Hospitals, Bengaluru, Karnataka, India

Date of Web Publication9-Oct-2014

Correspondence Address:
Himanshu Verma
Department of Vascular Surgery, Narayana Institute of Vascular Sciences, Narayana Hrudaylaya Hospitals, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0820.142367

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EVAR has emerged as procedure of choice for morphologically suitable AAAs. Due to direct perfusion of aneurysm sac at systemic blood pressure, types I & III endoleaks are indicated for interventions even when patients are asymptomatic or have stable aneurysm size. Disconnection of components of modular endograft system and defect in the stent-covering graft fabric has been classified as type III a & b endoleaks respectively. Due to an overall smaller incidence, descriptive management of Type III endoleaks has been limited to very few case reports and needs to be individualized.
We present a case of complex Type III a endoleak, 2 years following EVAR, where complete disjunction of main body and contralateral limb occurred with increase in aneurysm sac diameter. It was managed by brachio-femoral realignment and interposition stent graft. We also review the current literature on type III endoleak, its classification , risk factors and their management in current practice.

Keywords: Abdominal aortic aneurysm follow-up, endovascular aneurysm repair, type III endoleak

How to cite this article:
Verma H, Meda N, Tripathi RK. Management of Complex Type Iiia Endoleak by Brachio-femoral Realignment and Interposition Stent Graft and Review of the Literature. Indian J Vasc Endovasc Surg 2014;1:29-32

How to cite this URL:
Verma H, Meda N, Tripathi RK. Management of Complex Type Iiia Endoleak by Brachio-femoral Realignment and Interposition Stent Graft and Review of the Literature. Indian J Vasc Endovasc Surg [serial online] 2014 [cited 2019 Jun 26];1:29-32. Available from:

  Introduction Top

Endovascular aneurysm repair (EVAR) has been accepted as preferred line of treatment for morphologically suitable abdominal aortic aneurysms (AAAs). Persistent filling of aneurysm sac (endoleak) is a well-known complication and classified as types I-V. [1],[2] Due to direct perfusion of the aneurysm sac at systemic blood pressure, types I and III endoleaks are indicated for interventions even when patients are asymptomatic, and their AAA size is unchanged. Interventions in other types (II/IV/V) of asymptomatic endoleaks are not routinely considered except in instances of increase in size of AAA.

Here, we present a case of type III A endoleak, which was managed by realignment and interposition stent grafting, 2 years after the primary EVAR.

  Case Report Top

A 60-year-old male underwent EVAR for asymptomatic infrarenal AAA (maximum diameter 6.2 cm) in 2009.

Talent™ device (Medtronic Inc., Santa Rosa, CA, USA) (main body AF2816C170A, contralateral limb IW1414C105A) was used. EVAR was performed under strict instructions for use for the device (neck length 23 mm, neck angulation <30°, no thrombus or calcification in neck and nontortuous iliac arteries). Completion angiogram had no evidence of any endoleak. There was scissoring of limbs during the procedure.

Patient underwent post-EVAR surveillance via an institutional protocol (abdominal ultrasound and X-ray anteroposterior/lateral) views every 3 months 1 st year, 6 monthly in 2 nd year and annually thereafter.

Twenty-eight months after his initial EVAR, the patient underwent a computed tomography (CT) scan abdomen and pelvis for renal colic and was found to have an AAA of 6.5 cm diameter with disruption of continuity of one limb of the graft. On X-ray, mal-alignment of device's contralateral limb was noted [Figure 1]a which was then confirmed by contrast-enhanced CT aortogram [Figure 1]b. CT showed complete disjunction of the contralateral limb and a type III an endoleak.
Figure 1: (a) X-ray abdomen anteroposterior view showing disjunction of stent graft limb (white arrow), (b) contrast-enhanced computed tomography showing type III endoleak, (c) Intraoperative angiogram demonstrating modular component disjunction, (d) schematic diagram

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Endovascular attempt to resolve the problem utilizing a brachio-femoral realignment with interposition stent graft was planned. In the failure to do so, conversion to aorto uni-iliac device and cross over the fem-fem bypass was kept as a standby option.

Bilateral common femoral arteries were exposed by oblique skin incisions, and a 5 Fr Pigtail catheter (Cordis, Miami, FL, USA) was placed in the abdominal aorta through a 5 Fr left brachial sheath. Angiograms were performed via aortic pigtail catheter as well as retrograde contrast injection from femoral sheaths.

Complete disjunction of right (contralateral) limb was observed with the proximal end of the disconnected limb abutting against the dome of AAA with very little room for maneuver [Figure 1]c, d and [Figure 2]a. A 0.035„ glide wire was passed from right femoral sheath and guided toward the proximal contralateral gate using Simmons 2 catheter (Cordis, Miami, FL, USA) which was advanced just enough for the hairpin bend of the catheter to lie at the top end of the contralateral limb [arrow in [Figure 2]b]. The glidewire was then snared by Amplatz Goose Neck® Snare kit (ev3 Inc., Plymouth, MN) from the brachial artery [Figure 2]b and c. Balloon-aided brachio-femoral "flossing" was achieved. Hydrophilic glide wire was exchanged to 0.035„ Amplatz stiff wire (Boston Scientific Co., Natick, USA) [Figure 2]c. Realignment was achieved by  Atlas More Details™ Bard Peripheral Vascular, Tempe, AZ, USA noncompliant PTA (14 × 40 mm) balloon [Figure 2]d. Talent Iliac Extension IXW1616C80AXH (Medtronic Inc., Santa Rosa, CA, USA) was deployed as a bridge across the dislocated limb segments and angioplastied using (16 × 40 Atlas PTA balloon) from bilateral iliac limbs in a "kissing" fashion [Figure 2]e. Check angiogram showed no evidence of endoleak and patent bilateral stent graft limbs [Figure 2]f. Patient was kept in follow-up protocol of CT 6 monthly for 1-year and annually, thereafter. At 24 months follow-up, patient remains asymptomatic with no increase in the size of AAA and no evidence of new endoleak.
Figure 2: Steps of procedure: (a) Blowback angiogram from right endovascular aneurysm repair limb, (b) 0.035 "glide wire-guided towards main body gate guided by Simmons 2 catheter keeping hairpin bend of the catheter to lie at the top end of the contralateral limb (black arrow) and captured in Amplatz Goose Neck snare from top (white arrow), (c) Femoro -brachial flossing achieved, (d) Realignment was achieved by ATLASTM BARD noncompliant PTA balloon (14 × 40 mm) (e) Bridge stent graft deployed and angioplastied in kissing fashion, (f) Final angiogram

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  Discussion Top

Endoleaks have been most important cause of re-interventions in EVARs. Reported incidences of type I, II, and III endloeaks in few landmark trials have been shown in [Table 1]. [3],[4],[5],[6],[7],[8] Type III endoleaks are defined as trans-graft endoleaks. Further classification of type III endoleaks was described by Chaikof et al.[2] in 2002 under "Reporting standards for endovascular aortic aneurysm repair." It could occur either due to disconnection of components of modular endograft system (IIIa) or defect in the stent-covering graft fabric (IIIb). Type III b endoleaks is further stratified with respect to the extent of fabric disruption as major (>2 mm) or minor (<2 mm). [2] Incidence of type III endoleaks has been reported 1-11% [1],[2],[3],[4],[5],[6],[7],[8],[9] [Table 1]. Type III endoleak allows direct pressurization of the sac, which can lead to aneurysm growth and rupture. Harris et al. reported high risk of aneurysm rupture in the presence of type III endoleak (relative risk 8.95). [3] Depending on timing of appearance, it could be classified as primary: Identified during the index procedure, or secondary: Being identified in follow-up scans. With current generation devices and good competency of interventionists, primary type III endoleaks are uncommon and unacceptable.
Table 1: Reported incidence of Endoleaks in the world literature

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Also based on the complexity of the anatomy, type IIIa endoleak could be classified as simple and complex. Improper seal, inadequate overlap of modular components, and distal component migration are considered as simple type III endoleaks. Whereas, major component dislocation including total mal-alignment results in complex type IIIa endoleaks. Various possible risk factors for the development of type III endoleaks have been listed in [Table 2]. [1],[8],[10],[11],[12],[13],[14],[16]
Table 2: Risk factors for type III endoleak

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Sac remodeling is an important risk factor for complex type IIIa endoleaks. Although scissoring of limbs may appear to increase the incidence of limb dislocations during sac remodelling, Georgiadis et al. did not find any significant difference between compared outcomes for scissoring of limbs (also called as "Ballerina position") versus conventional endograft configuration during EVAR over a mean follow-up period of 29.9 months. [10] However, authors did not deny the possibility of stent graft fatigue and related complications in the future. Furthermore, as the number of limb extensions used increases, so do the number of junctions, further increasing the risk of junctional complications including type IIIa endoleak. [11]

With the advent of more complex fenestrated EVAR and TEVAR procedures, total number of junctions in endografts has increased with the possibility of a corresponding increase in the incidence of type III endoleaks. Type III endoleaks arising from side branches are a special concern after fenestrated endografting, with reported rates of 0% to 6.8% in different series. [12] Troisi et al. reported secondary procedures after aortic aneurysm repair with fenestrated and branched endografts. Type III endoleaks occurred in 9.3% of cases and were most common cause for re-intervention during follow-up. [8] Furthermore, there has been a progressive decrease in profile of EVAR devices at the cost of thinner fabric, and it would be of interest to see how well do these low profile devices behave in the long term.

For the treatment for type III endoleaks, simple or complex realignment with covered stents/iliac limb extensions or aorto uni-iliac grafting with femoro-femoral crossover bypass has been described. If endovascular solution is not possible, conversion to open repair with explantation of endograft is required. [13],[14],[15],[16]

Ours was a case of complex type IIIa endoleak due to modular component disjunction.

The key step of the procedure was to obtain femoro-brachial floss and realignment using noncompliant PTA balloon by tension on the brachial and femoral ends to bring the contralateral limb components together. This case also highlights that scissoring of iliac legs during EVAR may be avoided in complex AAA anatomy as it potentially exposes patient to risks of delayed complications, e.g. limb dislocation, limb occlusion.

  References Top

1.White GH, May J, Waugh RC, Chaufour X, Yu W. Type III and type IV endoleak: Toward a complete definition of blood flow in the sac after endoluminal AAA repair. J Endovasc Surg 1998;5:305-9.  Back to cited text no. 1
2.Chaikof EL, Blankensteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002;35:1048-60.  Back to cited text no. 2
3.Harris PL, Vallabhaneni SR, Desgranges P, Becquemin JP, van Marrewijk C, Laheij RJ. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: The EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm repair. J Vasc Surg 2000;32:739-49.  Back to cited text no. 3
4.De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven EL, Cuypers PW, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1881-9.  Back to cited text no. 4
5.United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-71.  Back to cited text no. 5
6.EVAR trial participants. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): Randomised controlled trial. Lancet 2005;365:2187-92.  Back to cited text no. 6
7.Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y, Lermusiaux P, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low-to moderate-risk patients. J Vasc Surg 2011;53:1167-1173.e1.  Back to cited text no. 7
8.Troisi N, Donas KP, Austermann M, Tessarek J, Umscheid T, Torsello G. Secondary procedures after aortic aneurysm repair with fenestrated and branched endografts. J Endovasc Ther 2011;18:146-53.  Back to cited text no. 8
9.Ouriel K, Clair DG, Greenberg RK, Lyden SP, O′Hara PJ, Sarac TP, et al. Endovascular repair of abdominal aortic aneurysms: Device-specific outcome. J Vasc Surg 2003;37:991-8.  Back to cited text no. 9
10.Georgiadis GS, Georgakarakos EI, Antoniou GA, Trellopoulos G, Argyriou C, Nikolopoulos ES, et al. Clinical outcomes after crossed-limb vs. conventional endograft configuration in endovascular AAA repair. J Endovasc Ther 2013;20:853-62.  Back to cited text no. 10
11.Karthikesalingam A, Holt PJ, Hinchliffe RJ, Nordon IM, Loftus IM, Thompson MM. Risk of reintervention after endovascular aortic aneurysm repair. Br J Surg 2010;97:657-63.  Back to cited text no. 11
12.Oderich GS. Reporting on fenestrated endografts: Surrogates for outcomes and implications of aneurysm classification, type of repair, and the evolving technique. J Endovasc Ther 2011;18:154-6.  Back to cited text no. 12
13.Schuurman JP, Fioole B, van den Heuvel DA, de Vries JP. Endovascular therapy for recurrent type III endoleak. Vasc Endovascular Surg 2010;44:123-5.  Back to cited text no. 13
14.Juszkat R, Staniszewski R, Zarzecka A, Majewski W. Diagnosis of type III endoleak and endovascular treatment with aortouniiliac stent-graft. J Vasc Interv Radiol 2009;20:125-9.  Back to cited text no. 14
15.Kassavin DS, Constantinopoulos G. Repair of a disconnected stent-graft limb facilitated by in situ fenestration. J Endovasc Ther 2012;19:434-8.  Back to cited text no. 15
16.Faries PL, Cadot H, Agarwal G, Kent KC, Hollier LH, Marin ML. Management of endoleak after endovascular aneurysm repair: Cuffs, coils, and conversion. J Vasc Surg 2003;37:1155-61.  Back to cited text no. 16


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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