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Effective proximal sealing, especially in the long-term, remains a limitation of contemporary endovascular aortic aneurysm repair (EVAR). Endostaples that fixate the proximal stent-graft to the aortic neck wall, aiming for better apposition and proximal sealing have been recently introduced in clinical practice to address this problem. Initial experimental studies have shown that endostaples can increase proximal stent-graft fixation to levels equivalent or superior to that of a hand-sewn anastomosis. Further clinical studies aimed to investigate whether this increased proximal fixation results in reduced migration and better sealing with lower rates of type I endoleak. The present chapter discusses the efficacy of endostaples in reducing migration and type I endoleak after EVAR, based on published clinical data.

The aim of this study is to describe our clinical experience with an extra-large self-expandable stent specifically designed to treat aortic lesions (E-XL, Jotec GmbH, Hechingen, Germany), now commercially available in Europe. The E-XL was used at our Institution in 14 patients (mean age, 56±12 years; 9 males) with the following indications: improve proximal fixation (4 cases), type I endoleak (2 cases), aortic dissection with static malperfusion (1 case) and dynamic malperfusion (7 cases). Early results have been shown to be safe and effective in different clinical settings, including in emergency cases. This peculiar aortic stent could be useful in the armamentarium of the endovascular surgeon.

Endovascular aortic repair (EVAR) necessitates lifelong surveillance for the patient, in order to detect complications timely. Endoleaks (ELs) are among the most common complications of EVAR. Especially type II ELs can have a very unpredictable clinical course and this can range from spontaneous sealing to aortic rupture. Subgroups of this type of EL need to be identified in order to make a proper risk stratification. Aim of this review is to describe the existing imaging techniques, including their advantages and disadvantages in the context of post-EVAR surveillance with a particular emphasis on low-flow ELs. Low flow ELs cause pressurization of the aortic aneurysm sac with a low velocity filling, leading to difficulty of detection by routine imaging protocols for EVAR surveillance, e.g. bi- or triphasic multislice computed tomographic angiography, magnetic resonance imaging and contrast enhanced ultrasound. In this article, we review the imaging possibilities of ELs and discuss the different imaging strategies available for depicting low flow ELs.

Aim: The aim of this paper was to review technical success and clinical outcome of reinterventions to treat complications after endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in a tertiary vascular center., Methods: The study enrolled 107 patients treated for post-EVAR complications between January 2005 and March 2014. Details of reinterventions, technical success, and midterm clinical outcome were analyzed for reinterventions. Radiologic follow-up after reinterventions was performed by computed tomography scans and duplex ultrasonography., Results: Indications for reinterventions in the 107 patients were predominantly endoleaks type Ia, Ib, II, and III (55.1%). Endograft obstructions were observed in 39 patients (36.4%). The initial technical success rate for the 107 reinterventions was 93.5% (N.=100). Median follow-up postreintervention was 20 months (range, 1-107 months). During follow-up, 34 of 107 patients (31.8%) needed at least one renewed reintervention. Kaplan-Meier analysis of overall survival after the primary reinterventions was 85% at 1 year, and 78% at 3 years of follow-up. AAA/EVAR-associated mortality was 4% at 3 years. Kaplan-Meier survival estimation of freedom of recurrence was 88% at 1 year post-reintervention and 78% at 3 years. Renewed reintervention-free survival dropped to 78% at 1 year and 58% at 3 years., Conclusion: In this series of patients, the technical success rate of reinterventions to treat post-EVAR complications was high. During a median follow-up of 20 months, AAA-associated mortality is low, but the need for renewed (endovascular) reinterventions is substantial.

Aim: Current commercially available modular stentgrafts are associated with relevant reintervention rates during follow-up. The Nellix Endovascular Aneurysm Sealing (EVAS) System is a potential device to overcome these limitations of EVAR. Device implantations outside of manufacturer instructions for use due to challenging neck anatomies are very common. This article presents very early experience in the treatment of patients with post EVAR complications and challenging neck anatomies., Methods: EVAS with the Nellix System consists of bilateral PTFE-covered stentgrafts surrounded by endobags which are filled with biostable polymer which cures after 3-5 minutes. The device and concept is designed to seal the entire aneurysm lumen, to withstand lateral displacement forces and effectively seal lumbar or inferior mesenteric arteries. Potentially, device migration, type II endoleak, and subsequent reinterventions will be reduced in the longterm. Single case experience in four European vascular centers is reported using Nellix off-IFU (instructions for use), addressing technical aspects as well as patient selection criterias., Results: Recent preliminary clinical experience using Nellix outide of the IFU in challenging neck anatomies prooves early feasibility and efficacy in patients being excluded for open repair (OR) and also for EVAR and FEVAR within OR. Short-term results are promising. Migration, renal artery occlusions or type II endoleaks were not observed. One type Ia endoleak was observed but was temporary and resolved. We also found that the chimney technique is feasible with Nellix, where secondary target vessel loss nor gutters were observed. The EVAS concept is a potential tool to treat post EVAR complications such as secondary type I endoleak or type IV material fatigue. Feasibility has been proven in single cases., Conclusion: EVAS is an innovative, intriguing concept in the treatment of abdominal aortic aneurysm (AAA). Short-term outcomes of the Nellix system is promising. Early experience of Nellix out of IFU when treating patients with challenging proximal infraenal necks, with post EVAR complications, short necks and chimney techniques show technical feasibility and promising short-term results. Mid- and long-term data are needed to validate device and procedure durability.

Endovascular aneurysm management (EVAR) is hampered by persistent arterial blood flow in the aneurysm sac after treatment, known as endoleak (EL). Type II EL consist of blood flow from one or more aortic branch vessels; they only require treatment when the aneurysm sac fails to shrink. Post-EVAR follow up is mostly done with contrast enhanced computed tomography. If a type II EL requiring treatment is found, a variety of options exist, depending on the source of EL and the anatomy. Inferior mesenteric artery EL is best treated by endovascular embolization through the superior mesenteric artery and Riolans' arc. In hypogastric to lumbar artery EL success of endovascular treatment is limited. In these cases a successful embolization of the EL can often be performed by a direct percutaneous approach to the EL inside the aneurysmal sac. CT guidance provides a good way to exactly puncture the EL percutaneously in most cases, but limited workspace and lack of fluoroscopy availability for the ensuing catheter manipulation hampers this technique. A novel way to puncture the EL and subsequently treat it is performed on flat panel detector angiography units. By a rotation around the patients these units provide the possibility to create a cone-beam CT (CBCT) in the angio suite. Using the 3-dimensional dataset thus acquired, a needle path can be planned and the EL nidus can be punctured with great confidence and without danger of inadvertently perforating vital structures. After the EL has been punctured, microcatheters can be inserted to embolize the origins of branch vessels and/or the aneurysm sac can be filled with thrombogenic agents or glue. CBCT guided procedures incur lower radiation dose and have higher accuracy compared to conventional CT guided procedures. Details of CBCT guided procedures; the materials and technique used are detailed in this manuscript.

Aim: Endovascular aortic repair (EVAR) is an adequate therapy for abdominal aortic aneurysms (AAA). Late aortic ruptures caused by endoleaks after EVAR still remain a critical issue. The aim of this study was to assess the causes of ruptured aortic aneurysms after EVAR in a single center study., Methods: All patients, who were treated in our University hospital with a ruptured juxtra- or infrarenal AAA between January 2011 and October 2013, were included in this retrospective analysis., Results: Thirty patients with ruptured infra- or juxtrarenal aneurysms were treated in this time frame. Six out of these 30 patients had previous EVAR repair. The median maximal aneurysm diameter of these post-EVAR patients was 82 (75-95) mm. The median time between primary EVAR and rupture was 42.5 (14-99) months. Three patients with type Ia endoleaks were treated by stent removal and conventional aortic reconstruction. In two patients with type II endoleak the bleeding was controlled by occluding the back bleeding lumbar arteries. One type III endoleak was sealed by an additional stent-graft implantation into the right iliac artery., Conclusion: We observed a considerable number of patients with a ruptured AAA after EVAR. Surprisingly, we observed two ruptured aneurysms due to type II endoleaks.

Aim: The aim of this paper was to evaluate short-term outcome of the use of endoanchors to secure the primary migrated endograft and additional extender cuffs to the aortic wall in patients with previous failed endovascular aortic aneurysm repair., Methods: Consecutive patients who needed proximal repair of a primary failed endograft due to migration (with or without type IA endoleaks) were treated with endoanchors, with or without additional extender cuffs. Data of this group were prospectively gathered in vascular referral centers that were early adopters of the endoanchor technique. Preprocedural and periprocedural data were prospectively gathered and retrospectively analyzed. Follow-up after endoanchor placement consisted of regular hospital visits, with computed tomography or duplex scanning at 1, 6, and 12 months., Results: From July 2010 to May 2011, 11 patients (8 men), mean age 77 years (range, 59-88 years), were treated with endoanchors for a failed primary endograft (2 Excluder endografts, 1 AneuRx endograft, and 8 Talent endografts) due to distal migration of the main body, with or without type IA endoleak. Revision consisted of using endoanchors to secure the body of the primary endograft to the aortic wall to avoid persistent migration. Most patients had additional proximal extender cuffs with suprarenal fixation, which were secured with endoanchors to the aortic wall and in some patients also to the primary endograft. A median of 6 endoanchors were implanted. All endoanchors were positioned correctly but one. One endoanchor dislodged but was successfully retrieved using an endovascular snare. During a mean follow-up of 10 months (range, 3-18 months) no endoanchor-related complications or renewed migration of the endografts occurred. Two patients underwent repeat intervention due to persistent type IA endoleak during follow-up., Conclusion: The use of endoanchors to secure migrated endografts to the aortic wall is safe and feasible and might help to overcome persistent migration of primary failed endografts. In combination with the use of sole extender cuffs the majority of proximal EVAR failures can be solved.

Endoleaks are one of the most common reasons for reinterventions and failure after endovascular aneurysm repair (EVAR). Current classifications divide endoleaks into type I-V but a more pragmatic definition is of direct and indirect endoleaks. Direct endoleaks (type I and III) transmit direct systemic pressure to the aneurysm sac and carry a high risk of aneurysm growth and rupture if left untreated. Immediate intervention is generally warranted. Indirect endoleaks (type II, IV, V) may have a more benign course and should be treated only under the presence of aneurysm growth. Appropriate procedural planning and device selection is critical to avoid endoleaks and most direct endoleaks can be identified and treated periprocedurally by use of high quality intraoperative imaging techniques. Late endoleaks can be treated predominately by endovascular means and the need for conversion to open surgery is rare.

Growing concerns regarding radiation exposure, contrast induced nephropathy and increasing costs lead us to reconsider the necessity of CTA for all EVAR patients. The purpose of this study is to compare the results of different follow-up imaging modalities with the aim of finding a rationale to the optimal follow-up imaging protocol. We reviewed recent literature regarding post EVAR imaging modalities and compared it to our experience with different follow-up protocols. Modalities compared were CTA, DUS, CEUS, and plain abdominal X-ray with regard to detection of complications, cost, overall impact to the patient, and on decision making regarding reintervention. CTA is related to increased follow-up costs and a much higher exposure to radiation compared to other modalities. The cumulative radiation dose can have a significant impact on the attributable lifetime cancer risk of patients. Renal function deterioration during post EVAR follow-up is higher compared to open repair. Plain abdominal X-ray is the best manageable modality and a well established tool in documenting migration kinking and stent fracture. Plain X-Ray cannot be used as a standalone imaging modality since it doesn't allow direct detection of endoleaks. As far as detection of endoleaks is concerned recent meta-analyses show a sensitivity of 66-77% for DUS and 81-98% for CEUS, respectively. Most endoleaks missed by DUS and CEUS are type II endoleaks with no need for reintervention. Our data in a cohort of 62 patients do show a sensitivity of 66.7% for DUS, and do correlate with current literature. No endoleaks requiring reintervention were missed. A follow-up protocol comprising of DUS/CEUS and plain abdominal X-ray gives a wide range of information covering EVAR related risks and is associated with less radiation exposure, avoidance of renal function deterioration due to repeated contrast agent application and an important decrease in the cost of EVAR follow-up. CTA should be reserved for cases of inconclusive ultrasound, signs of complications and unfavourable anatomy.