Diana Losada, MD, FRCSC, Francois Julien, MD, FRCSC, Joseph Mamazza, MDCM, FRCSC, Jean Denis Yelle, MD, FRCSC, FACS. Minimally Invasive Surgery, Division of General Surgery, The Ottawa Hospital, University of Ottawa.
INTRODUCTION: An endoleak is a persistent blood flow in the aneurysm sac extrinsic to the endograft. It is the most common complication after endovascular aneurysm repair (EVAR), reported to occur in 10% to 30% of patients. Type II endoleak results from collateral retrograde flow usually from the lumbar arteries, inferior mesenteric artery, or median sacral artery. In general, they are thought to be clinically benign and treatment is reserved for endoleaks associated with enlargement of the aneurysm sac.
We report a case of a 80-year-old patient who had a persistent Type II endoleak after endovascular repair of an abdominal aortic aneurysm (AAA). The endoleak was repaired with laparoscopy ligation of the median sacral artery.
CASE REPORT: An 80-year-old male patient underwent an uneventful endovascular repair of 5.9 cm infrarenal abdominal aortic aneurysm in September 2009. Routine CT scan in 2012 revealed a type II endoleak and the aneurysm sac enlarged at 6.6 cm. An angiogram identified an Endoleak that appeared to be fed by retrograde flow in the median sacral artery with outflow to the L5 lumbar branches (Fig. 1). Unfortunately, embolization was not feasible.
Fig. 1 The endoleak was visualized, the main arterial supply is retrograde flow within the median sacral artery.
The patient was taken to the operating room for a laparoscopic ligation of the median sacral artery. The camera was placed in the umbilicus using an open technique. Two others ports 12mm and 5mm were placed in the right side and one 5mm in the left side. The patient was placed in steep Trendelenburg. The rectosigmoid was then pulled out of the pelvis. The right limb of the graft was identified, it was large and thrombosed. The space between the aortic bifurcation was dissected with the hook electrocautery to expose the sacral promontory. The left femoral vein was identified. The median sacral artery was found and double clipped (Fig. 2). There were no intraoperative or post-operative complications.
Fig. 2 Laparoscopic ligation of the median sacral vessel.
DISCUSSION: Repair of Type II endoleaks can be accomplished by endovascular or open surgical techniques. Laparoscopic repair of endoleaks may offer another useful method in the treatment of refractory endoleaks. Richardson et al. were successful in two patients using laparoscopic ligation to stop back bleeding from the inferior mesenteric artery in expanding aneurysms after EVAR with low morbidity and no mortality. Our case is the first reported case of a laparoscopic ligation of middle sacral artery done to repair a type II endoleak. Few studies described a technique of laparoscopic ligation of the median sacral artery before the resection of a sacrococcygeal teratoma.
In summary, the laparoscopy ligation offers a viable alternative in the management of select persistent type II endoleaks following endovascular aneurysm repair.