Endoleakage after stent-graft treatment of abdominal aneurysm: Implications on pressure and imaging - an in vitro study

Background: Endoleakage is a fairly common problem after endovascular repair of abdominal aortic aneurysm and may prevent successful exclusion of the aneurysm. The consequences of endoleakage in terms of pressure in the aneurysmal sac are not exactly known. Moreover, the diagnosis of endoleakage is a problem because visualization of endoleaks can be difficult. Method: With an ex vivo model of circulation with an artificial aneurysm managed by means of a tube graft, studies were performed to evaluate precisely known diameters of endoleaks with both imaging techniques (computed tomography and digital subtraction angiography) and pressure measurements of the aneurysmal sac. The experiments were performed without endoleak (controls) and with 1.231-French (0.410 nun), a-French (1 mm), and 7-french (2.33 nun) endoleaks. Pressure and imaging were evaluated in the absence and presence of a simulated open lumbar artery. The pressure in the prosthesis and in the aneurysmal sac were recorded simultaneously. Digital subtraction angiography with and without a Lucite acrylic plate, computed tomographic angiography, and delayed computed tomographic angiography were performed. For the first experiments, the aneurysmal sac was filled with starch solution. All tests were repeated with fresh thrombus in the aneurysmal sac. Results: Each endoleak was associated with a diastolic pressure in the aneurysmal sec that was identical to diastolic systemic pressure, although the pressure curve was damped. At digital subtraction angiography without a Lucite acrylic plate, the 1.231-French (0.410 mm) endoleak was visualized without an open lumbar artery. When a Lucite acrylic plate was added, the endoleak was not visible until a lumbar artery was opened. In the presence of thrombus within the aneurysmal sac, all endoleaks mere not visualized at digital subtraction angiography. At computed tomographic angiography, all endoleaks were not visualized in the absence of a thrombus mass in the aneurysmal sac, In the presence of thrombus within the aneurysmal sac, the 1.231-French (0.410 nun) endoleak became visible after opening of a simulated lumbar artery. At delayed computed tomographic angiography; all endoleaks were visualized without and with thrombus. Conclusion: Every endoleak, even a very small one, caused pressure greater than systemic diastolic pressure within the aneurysmal sac. However, small endoleaks were not visualized with digital subtraction angiography and computed tomographic angiography, whereas all endoleaks were visualized with a delayed computed tomographic angiography protocol. We believe that follow-up examinations after stent graft placement for aortic aneurysms should focus on pressure measurements, but until this is clinically feasible, delayed computed tomographic angiography should be performed.