Iliac Aneurysm & Endoleak

Grace Kuo M3August 2013

Clinical Scenario• CC - epigastric pain, nausea and vomiting for 1 day. • HPI - 69 y/o Male presents w/ abdominal pain + N/V for 1 day. • Pain is epigastric, aching and pressure like, does not radiate, severity is

moderate. Had one episode of non-bilious non-bloddy emesis the night before hospitalization. On 2nd day of hospital stay, described more lower abdominal, suprapubic pain.

• PMHx – R. iliac artery aneurysm s/p endograft (2010), SLE, HTN, hypercholesterolemia, rheumatoid arthritis, CKD, anemia, dementia, esophagitis.

• ROS is otherwise negative.• Meds: Pantoprazole 40mg PO, Ferrous sulfate 325 mg PO,

prednisone 6 mg PO, alendronate 35 mg PO, Pravastatin 40 mg, Lisinopril 40 mg PO, Allopurinol 100 mg PO, Aspiring 81 mg PO, Vitamin B12 PO, B complex 1 capsule PO

Physical Exam• NIBP: 157/87 mmHg (08/05/13 0800) • BP: 156/80 mmHg (08/05/13 1015) • Pulse: 86 (08/05/13 1015) • Temp: 97.3 °F (36.3 °C) (08/05/13 1015) • Resp: 20 (08/05/13 1015) • Weight: 72.576 kg (160 lb) (08/05/13 0600) • SpO2: 98 % (08/05/13 1015)

• CONSTITUTIONAL: Awake, alert, cooperative, appears in mild distress, appears stated age • EYES: Lids and lashes normal, sclera clear, conjunctiva normal • LUNGS: No increased work of breathing, good air exchange, clear to auscultation

bilaterally, no crackles or wheezing • CARDIOVASCULAR: RRR, normal S1 and S2, no S3 or S4, and no murmur noted • ABDOMEN: No scars, normal bowel sounds, soft, non-distended,tender to deep palpation

near epigastric region and left lower quadrant, no abdominal bruits appreciated on exam • MUSCULOSKELETAL: There is no redness, warmth, or swelling of the joints. Peripheral

pulses on lower extremities difficult to assess

Differentials

• Esophagitis – recent history• SLE makes patient more susceptible to vasculitis, ulcers,

and gastritis, all of which may present as abdominal pain• Bowel obstruction• Aneurysm – Iliac artery aneurysms are highly correlated

with AAA.

• Due to high BUN (32) and Cr levels (1.8), CT was first obtained w/o contrast, and revealed enlargement of right common iliac aneurysm (9.1x8.6 cm). Endoleak of previous graft was suspected. • CT Abdomen-Pelvis w/o IV Contrast AX (8-6-2013)

Comparison: CT Abdomen 2010

CT Prior to aneurysm repair. Aneurysm measured to be 6.5 x 6.3 cm.

Post graft CTA 2010 Pre contrast

CTA 2010 post contrast

CTA post endograft (2010) – Delayed

Further Aneurysm Evaluation• CT Angiogram of Abdomen & Pelvis were obtained 8/7/2013• CTA – Pre contrast:

CTA – post contrast

CTA-Delayed

Imaging Results• CT Abdomen-Pelvis w/o contrast showed 9.1x8.6 cm

aneurysm. Previous CT from 2010 showed aneurysm size of 6.5x6.3 cm.

• From CTA:• Hyperdensity in the aneurysmal sac in delayed view – leakage

into the aneurysmal sac, confirming the presence of endoleak.

• Anterior fat stranding – suggestive of pathological processes such as a contained leak in the aneursymal sac. Other differentials include inflammation.

Types of Endoleaks• Type I – leak at the proximal or distal attachment sites of graft

• Type II – blood leaks into the aneurysmal sac via accessory arterial branches

• Type III – graft defect (holes, defects, or separations in graft)

• Type IV – porous graft walls

• Type V – endotension - enlarging aneurysmal sac w/o visible leak.

Management for Endoleaks

• Type I – Angioplasty alone, or re-stent

• Type II – embolization of feeding artery

• Type III – place new stent graft material over the defective portion.

• Type IV – usually self-resolving.

• Type V – re-do the stent graft placement.

Patient was admitted to SICU, for vascular repair.

• Overlapping covered stents were placed in the right common/external iliac artery, however post stent deployment demonstrates residual contrast opacification of the aneurysmal sac, suggesting a type II endo-leak• leak was evaluated to be a type 2 endoleak.• Feeding artery deemed to be the circumflex femoral artery, which

was subsequently embolized.

• Prognosis: Unfortunately, type 2 endo-leaks have a high rate of recurrence after single vessel embolization. The idea is that type 2 endoleaks are often due to a network of vessels feeding into the aneurysmal sac, single vessel embolization may not resolve the problem completely, and aneurysmal sac can continue to expand. Patient will need close follow up.

IR Pelvic Angiogram (8/7/2013):

2 overlapping 9x59 mm & single 10x38 mm covered stents were deployed in the right common/external iliac artery and profiled with 12 mm balloon were inserted. Femoral Circumflex Artery was embolized.

Patient was discharged on 8/11/2013

THE END• Sources:• White, Sarah, and S. Stavropoulos. "Management of Endoleaks

following Endovascular Aneurysm Repair." Seminars in Interventional Radiology 26.01 (2009): 033-38. Web.