Repairing immediate proximal endoleaks during abdominal aortic aneurysm repair.

INTRODUCTION: Successful endovascular exclusion of abdominal aortic aneurysms is largely dependent on adequate apposition of the stent graft to the aortic wall. Proximal endoleaks at the time of stent graft placement are uncommon but are more prevalent in patients with challenging neck anatomy. If these initial leaks do not respond to simple balloon angioplasty, Palmaz stents (Cordis Endovascular, Warren, NJ) and covered stent graft cuffs both have been used to seal the endoleak. Long-term data regarding the efficacy of one method over the other, however, is lacking.

METHODS: We retrospectively reviewed a database of all infrarenal aortic aneurysm repairs with an intraoperatively diagnosed type Ia endoleak requiring Palmaz stent or covered stent graft cuff placement. Fenestrated and branch grafts were excluded. All records and appropriate imaging studies were reviewed. The primary end points were technical success of aneurysm exclusion, recurrence of a type Ia leak, and need for reintervention.

RESULTS: At the time of the initial aneurysm repair, 72 patients required an adjunctive covered extension or Palmaz stent; of these, 24 (33%) underwent sole placement of a Palmaz stent, 45 (62.5%) underwent placement of a covered stent graft cuff, and 3 required both a cuff and a Palmaz stent. Aneurysmal exclusion was successful in all patients before leaving the operating room. No recurrent type Ia endoleak developed in patients who underwent Palmaz stent placement. Of the 45 patients who underwent cuff placement, proximal leaks developed in 3 that required reintervention: 1 was managed with a Palmaz stent and the other 2 required open surgical revision.

CONCLUSIONS: Palmaz stent placement and stent graft cuff placement are frequently used to seal immediate proximal endoleaks that do not resolve with balloon angioplasty. Both methods appear to be durable long-term options to facilitate endovascular exclusion of abdominal aortic aneurysms.