Management of type II endoleak

Endovascular aneurysm repair [EVAR] is associated with a persistent risk of endoleak. Collateral vessel endoleak [type II] is the most prevelant and is unpredictable in behavior. The objective of this report is to evaluate the prevelance of type II endoleak and the interventions required for its treatment. Over a 3 year period, 79 patients had EVAR, Endoleak was identified in 18 cases [22.8%] on computerized tomography. One patient had type I endoleak [5.6%], two had type Ill endoleak [11.1%], and fifteen [83.3%] had type II endoleak. Of the 15 patients with type II endoleak 12 [80%], were embolized, one was converted to open aneu- rysm repair [6.6%], and two required no intervention [13.3%]. Embolization was performed using coils in 3 patients; two of which had to be reembolized using biologic glue. A total of 11 patients were embolized using biologic glue. Patients were followed by CT scans at 1, 3, and 6 months. Out of 18 patients with endoleak, only one patient had conversion to open aneurysm repair [5.6%]. Embolization was attempted in 13 patients with type II endoleak and was successful in exclusion of the aneurysm in 2 [92.3%]. The type II endoleak was from the IMA in 4 patients [26.7%] and from the lumbar arteries in 11 patients [73.3%]. We had no neurologic complications or bowel ischemia secondary to embolization. All aneurysms that were treated remained successfully excluded at follow-up. Type II endoleak after EVAR is not uncommon. Patients after EVAR need to be followed for detection of endoleaks. Type II endoleaks can be treated effectively and safely. Procedures were performed during the period from August 1, 2004 to August 1, 2007 at Geisinger Medical Center, PA and Hillcrest Hospital, Cleveland. Ohio, USA

Endovascular management of malignant pelvic venous obstruction

Extrinsic compression of iliac veins by pelvic malignancy can cause massive leg swelling. Patients in whom the tumour size can not be reduced require relief of the venous obstruction for palliation. The objective of this study is to evaluate if stenting of the iliac veins can safely achieve this goal. Over a 2 year period 7 consecutive patients with malignant iliac vein obstruction were treated by percutaneous self expanding stents. In 2 patients mechanical thrombectomy was also required. Patients were evaluated by venous duplex and CT scan with intravenous contrast prior to intervention. All patients received oral anticoagulation postoperatively. Patients were evaluated by venous duplex at 1, 3 and 6 months. In the 7 patients treated there was significant reduction in limb size within 2-3 days. There were no mortalities. Venous duplex showed patent stents in all patients at one month [100%]. At 3 months one iliac vein stent thrombosed and 6 remained patient [85.7%]. At 6 months 2 patients have expired secondary to their malignant disease. The surviving patients remained asymptomatic with patent stents. Massive leg edema secondary to malignant iliac venous obstruction can be a cause of significant patient excluded morbidity. If the tumour size cannot be reduced iliac venous stenting provides good palliation and is safe

Revascularization of chronic mesenteric ischemia

Significant stenosis of one of the visceral arteries is not uncommon. Most of these stenoses are not associated with chronic mesenteric ischemia. Patients presenting with chronic mesenteric ischemia [CMI] are usually at high risk for surgery because of atherosclerosis and malnutrition. The objective of this study is to evaluate the endovascular treatment as a first line for treatment of CMI. This is a review of 15 consecutive patients who had intervention for CMI over a 2 years period. Patients with post prandial pain [15 patients - 100%] and weight loss [11 patients - 73.3%] were evaluated by duplex ultrasound and CT angiogram. The SMA had complete occlusion in 6 [40%], ostial stenosis in 6 [40%] and stenosis of the proximal segment in 3 [20%] patients. Endovascular treatment was attempted in all patients. Sixteen arteries were stented in 12 patients. The SMA only was stented in 8 patients [53.3%], both the celiac and SMA were stented in 4 patients [26.7%] and bypass was performed in 3 patients [20%]. The bypass was from the supraceliac aorta to the celiac and SMA in 2 patients and iliac to SMA in one patient. The endovascular treatment was performed via a left brachial approach in 9 patients [75%], the femoral in 2 patients [16.7%] and the right brachial in one [8.3%]. The mean age was 78 years and 66.7% were women [10 patients]. Endovascular intervention was technically successful in 12 patients [80%] and surgical bypass was performed in the remaining 3 patients [20%]. There was no perioperative mortalities. All patients who had weight loss gained weight [100%] and 11 patients [73.3%] had complete resolution of post prandial pain. The restenosis rate was 26.7% [4 patients] at a mean follow-up of 8 months. All patients with restenosis were asymptomatic. Endovascular reintervention was successful in 3 patients [75%]. Despite the high restenosis rate, endovascular intervention provides a safe and effective first line of treatment. Surgical bypass is reserved for patients in whom endovascular treatment was unsuccessful. Patients with recurrent stenosis are often asymptomatic