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Complications following endovascular abdominal aortic aneurysm repair

Departments of ¹ Radiology and ² Vascular Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK

View larger version (194K): [in a new window]   Figure 1. Computer-generated image illustrating a modular, two-piece bifurcated graft. The main component comprises a body and one limb, introduced from the left femoral artery in this case (curved arrows). There is a short limb in the main component on the sideopposite to that of introduction (straight arrow). An extension limb (open arrows) is docked with this short limb to complete the bifurcated device.

View larger version (128K): [in a new window]   Figure 2. Plain anteroposterior abdominal radiograph showing a stent-graft passing from the aorta into the right common iliac artery; this is an aorto-uni-iliac device. A separate component covered with fabric is used to occlude the left common iliac artery (arrow).

View larger version (127K): [in a new window]   Figure 3. Axial contrast enhanced CT showing a well defined, contrast-filled space surrounding the metal frame of this stent-graft (arrows). In this device the fabric is on the outside of the stent and is sutured only at the proximal and distal ends. The fabric thus billows away from the stent giving the false impression of perigraft flow.

View larger version (114K): [in a new window]   Figure 4. Anteroposterior plain radiograph showing a bifurcated stent-graft. There are radio-opaque markers at the top and bottom of the short limb of this bifurcated device (solid arrows). The third pair of radio-opaque markers is at the top of the limb (open arrow), which has been introduced from the right groin to overlap this short leg, completing the bifurcated device. Embolisation coils can be seen at the origin of the inferior mesenteric artery (curved arrow).

View larger version (101K): [in a new window]   Figure 5. (a) The arrows point to fractures within the stent rings in the upper body of this device. (b) Thearrowpoints to separation of the stents within the body of this device owing to breakage of sutures designedtohold these components together. The apices of the stents may ultimately erode the fabric in this situation.

View larger version (96K): [in a new window]   Figure 6. (a) Lateral abdominal radiograph showing the superior extent of this stent-graft lying at the level of the L1/2 disc (arrow). This stent-graft is composed of individual nitinol wires attached to the graft material. The individual serpentine graft wires are not sutured together unlike the device shown in Figure 5b. The separation of thestents in this device is a normal feature and is not owing to suture breakage. (b) 2 years later the stent-graft has migrated distally and the top stent now lies at the level of the lower L2 vertebral body (arrow). There is angulation of the device anteriorly owing to some buckling as the proximal end migrated distally.

View larger version (120K): [in a new window]   Figure 7. This device has become markedly distorted. The marker at the distal end of the right limb can now be seen to lie within the aneurysm sac (arrow). This is owing to dislocation of this component from its attachment site in the right common iliac artery.

View larger version (107K): [in a new window]   Figure 8. There has been separation at the connection between the components of this modular bifurcated device. There is no longer continuity of the stent system between the radio-opaque markers, which can be seen to have separated (arrows).

View larger version (88K): [in a new window]   Figure 9. Colour is clearly seen within the limbs of this bifurcated device. There is no flow in the surrounding thrombus.

View larger version (90K): [in a new window]   Figure 10. (a) Axial colour Doppler image at the level of the proximal aorta. Colour can be seen outside the limits of the stent-graft (arrows), in keeping with endoleak. (b) CT confirms the presence of endoleak with a contrast blush within the aneurysm outside the confines of the stent-graft (curved arrows). (c) Spectral Doppler confirms the presence of arterial flow outside the stent-graft. The arrow points to the Doppler cursor, which is in the aneurysm sac behind the stent-graft.

View larger version (105K): [in a new window]   Figure 11. Axial contrast enhanced CT at the level of the proximal aneurysm. There is a large endoleak related to the proximal graft (arrows). This is a Type 1, or graft-related, endoleak.

View larger version (142K): [in a new window]   Figure 12. There is endoleak at the level of the distal aortic sac owing to incomplete seal of the right iliac limb (arrow). This is a distal Type 1, graft-related endoleak.

View larger version (54K): [in a new window]   Figure 13. (a) There is a contrast blush arising from the anterolateral aspect of the aorta on the left (curved arrow) and a small area of calcification at this level. This is the origin of the inferior mesenteric artery. This is a type 2, side branch endoleak. There is also some peri-aneurysmal fibrosis (solid arrow), which has obstructed the right ureter (open arrow). (b) There is a faint blush between the limbs of the stent-graft (curved arrow) at the level of the left L4 lumbar artery (straight arrows). This was confirmed angiographically as a Type 2 lumbar endoleak.

View larger version (60K): [in a new window]   Figure 14. (a) There is calcification within the mural thrombus posteriorly on the left before endovascular repair (arrow). (b) There is calcification and high density within the thrombus outside the stent-graft (arrow). This should not be confused with endoleak, as this conforms to the appearances on the pre-operative image.

View larger version (164K): [in a new window]   Figure 15. This aneurysm has an irregular shape and there is no true diameter of this non-geometric shape. A range of diameters may be selected: anteroposterior, transverse or oblique. The resulting diameter varies from 7.1 cm to 8.3 cm. Consistency in the choice of diameter is necessary to avoid the false impression of aneurysm growth on follow-up studies.