Laparoscopic Ligation of a Type II Endoleak from the Inferior Mesenteric Artery

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Author: David Schwartzberg
Published:
Specialties: General Surgery, Vascular Surgery
Schools: NYU Langone Medical Center, New York University Langone Medical Center
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Basic Info

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

Advanced

Procedure

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.

Indications

Persistent flow from a branch vessel into the aneurysm sac, with associated sac expansion.

Contraindications

Inability to tolerate laparoscopy, hostile abdomen, presence of type I or type III endoleak unless treated concurrently

Instrumentation

Setup

Patient supine with pressure points padded.

Preoperative Workup

Cross sectional Imaging, likely CTA, possibly only an U/S Aorta

Anatomy and Landmarks

Retroperitoneum once small bowel and mesentery is retracted cephalad

Advantages/Disadvantages

Compared to open repair techniques such as sacotomy and oversewing of the branch vessel or graft explant and open aneurysm repair, laparoscopic branch vessel ligation involves significantly lower operative risk. Laparoscopy allows for access to the branch vessel in question at its origin from the aneurysm sac more easily in many cases than retrograde transarterial access, which minimizes the chances of failure due to insufficiently proximal ligation/embolization. Unless paired with arteriography or perhaps expert proximal and distal graft intraoperative ultrasonography, laparoscopic repair is likely less able to detect occult type I or type III endoleaks.[3]

Complications/Risks

Bleeding, infection, damage to bowel

Disclosure of Conflicts

Bleeding, infection, damage to bowel

Acknowledgements

Gregory Westin, Paresh Shah and NYU Langone Medical Center, Divisions of General Surgery and Vascular/Endovascular Surgery

References

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

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