You have gained maximum
CME credits this year.
Your CME credits will reset next year. You can still continue to watch our videos.
Contributors: Gregory Westin and Paresh Shah
Endovascular stent grafting (EVAR) is now the preferred approach to repair of abdominal aortic aneurysms for many patients. One of the most common complications associated with EVAR is the development of an endoleak, or continued flow of blood into the aneurysm sac outside the graft. Type II endoleaks, those due to retrograde flow through a branch vessel such as the inferior mesenteric artery (IMA) or a lumbar artery, are the most common. Options for treatment include transarterial embolization, translumbar embolization, and laparoscopic ligation. Embolization techniques require reintervention in approximately 20%, with less than half free from aneurysm sac growth at five years, though current evidence is insufficient to determine a clear threshold for intervention or optimal technique.[1,2]
DOI#: http://dx.doi.org/10.17797/wu4visdfw2
Here we present the technique of laparoscopic IMA ligation, along with technical suggestions to ensure procedural success such as the use of an intraoperative laparoscopic ultrasound probe. In a center with the relevant laparoscopic technical expertise, this approach may prove more durable than embolization.
Persistent flow from a branch vessel into the aneurysm sac, with associated sac expansion.
Inability to tolerate laparoscopy, hostile abdomen, presence of type I or type III endoleak unless treated concurrently
Laparoscope
Patient supine with pressure points padded.
Cross sectional Imaging, likely CTA, possibly only an U/S Aorta
Retroperitoneum once small bowel and mesentery is retracted cephalad
Bleeding, infection, damage to bowel
Bleeding, infection, damage to bowel
1. Sarac TP, Gibbons C, Vargas L, Liu J, Srivastava S, Bena J, Mastracci T, Kashyap VS, Clair D. Long-term follow-up of type II endoleak embolization reveals the need for close surveillance. J Vasc Surg. 2012 Jan;55(1):33�40. PMID: 22056249
2. Karthikesalingam A, Thrumurthy SG, Jackson D, Phd EC, Sayers RD, Loftus IM, Thompson MM, Holt PJ. Current evidence is insufficient to define an optimal threshold for intervention in isolated type II endoleak after endovascular aneurysm repair. J Endovasc Ther Off J Int Soc Endovasc Spec. 2012 Apr;19(2):200�208. PMID: 22545885
3. Aziz A, Menias CO, Sanchez LA, Picus D, Saad N, Rubin BG, Curci JA, Geraghty PJ. Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion. J Vasc Surg. 2012 May;55(5):1263�1267. PMID: 22322122
Sign in to write a review
Reviews are open to CSurgeries members. Sign in to share your feedback on this case.
Sign in Don’t have an account? Create one freeHave a question about this case? Send a note to Dr. David Schwartzberg — they'll reply by email.
This is approved for 0.5 AMA PRA Category 1 Credit™ via CineMed (ACCME / ACPE / ANCC). The two viewing modes are different — pick what fits your time.
"*" indicates required fields