1. Iliac Aneurysm & Endoleak Grace Kuo M3 August 2013

2. Clinical Scenario CC - epigastric pain, nausea and vomiting for 1 day. HPI - 69 y/o Male presents w/ abdominal pain + N/V for 1 day. Pain is epigastric, aching and pressure like, does not radiate, severity is moderate. Had one episode of non-bilious non-bloddy emesis the night before hospitalization. On 2 nd day of hospital stay, described more lower abdominal, suprapubic pain. PMHx – R. iliac artery aneurysm s/p endograft (2010), SLE, HTN, hypercholesterolemia, rheumatoid arthritis, CKD, anemia, dementia, esophagitis. ROS is otherwise negative. Meds: Pantoprazole 40mg PO, Ferrous sulfate 325 mg PO, prednisone 6 mg PO, alendronate 35 mg PO, Pravastatin 40 mg, Lisinopril 40 mg PO, Allopurinol 100 mg PO, Aspiring 81 mg PO, Vitamin B12 PO, B complex 1 capsule PO

3. Physical Exam NIBP: 157/87 mmHg (08/05/13 0800) BP: 156/80 mmHg (08/05/13 1015) Pulse: 86 (08/05/13 1015) Temp: 97.3 °F (36.3 °C) (08/05/13 1015) Resp: 20 (08/05/13 1015) Weight: 72.576 kg (160 lb) (08/05/13 0600) SpO2: 98 % (08/05/13 1015) CONSTITUTIONAL: Awake, alert, cooperative, appears in mild distress, appears stated age EYES: Lids and lashes normal, sclera clear, conjunctiva normal LUNGS: No increased work of breathing, good air exchange, clear to auscultation bilaterally, no crackles or wheezing CARDIOVASCULAR: RRR, normal S1 and S2, no S3 or S4, and no murmur noted ABDOMEN: No scars, normal bowel sounds, soft, non-distended,tender to deep palpation near epigastric region and left lower quadrant, no abdominal bruits appreciated on exam MUSCULOSKELETAL: There is no redness, warmth, or swelling of the joints. Peripheral pulses on lower extremities difficult to assess

4. Differentials Esophagitis – recent history SLE makes patient more susceptible to vasculitis, ulcers, and gastritis, all of which may present as abdominal pain Bowel obstruction Aneurysm – Iliac artery aneurysms are highly correlated with AAA.

5. Due to high BUN (32) and Cr levels (1.8), CT was first obtained w/o contrast, and revealed enlargement of right common iliac aneurysm (9.1x8.6 cm). Endoleak of previous graft was suspected. CT Abdomen-Pelvis w/o IV Contrast AX (8-6-2013)

6. Comparison: CT Abdomen 2010 CT Prior to aneurysm repair. Aneurysm measured to be 6.5 x 6.3 cm.

7. Post graft CTA 2010 Pre contrast

8. CTA 2010 post contrast

9. CTA post endograft (2010) – Delayed

10. Further Aneurysm Evaluation CT Angiogram of Abdomen & Pelvis were obtained 8/7/2013 CTA – Pre contrast:

11. CTA – post contrast

12. CTA-Delayed

13. Imaging Results CT Abdomen-Pelvis w/o contrast showed 9.1x8.6 cm aneurysm. Previous CT from 2010 showed aneurysm size of 6.5x6.3 cm. From CTA: Hyperdensity in the aneurysmal sac in delayed view – leakage into the aneurysmal sac, confirming the presence of endoleak. Anterior fat stranding – suggestive of pathological processes such as a contained leak in the aneursymal sac. Other differentials include inflammation.

14. Types of Endoleaks Type I – leak at the proximal or distal attachment sites of graft Type II – blood leaks into the aneurysmal sac via accessory arterial branches Type III – graft defect (holes, defects, or separations in graft) Type IV – porous graft walls Type V – endotension - enlarging aneurysmal sac w/o visible leak.

15. Management for Endoleaks Type I – Angioplasty alone, or re-stent Type II – embolization of feeding artery Type III – place new stent graft material over the defective portion. Type IV – usually self-resolving. Type V – re-do the stent graft placement.

16. Patient was admitted to SICU, for vascular repair. Overlapping covered stents were placed in the right common/external iliac artery, however post stent deployment demonstrates residual contrast opacification of the aneurysmal sac, suggesting a type II endo-leak leak was evaluated to be a type 2 endoleak. Feeding artery deemed to be the circumflex femoral artery, which was subsequently embolized. Prognosis: Unfortunately, type 2 endo-leaks have a high rate of recurrence after single vessel embolization. The idea is that type 2 endoleaks are often due to a network of vessels feeding into the aneurysmal sac, single vessel embolization may not resolve the problem completely, and aneurysmal sac can continue to expand. Patient will need close follow up.

17. IR Pelvic Angiogram (8/7/2013): 2 overlapping 9x59 mm & single 10x38 mm covered stents were deployed in the right common/external iliac artery and profiled with 12 mm balloon were inserted. Femoral Circumflex Artery was embolized. Patient was discharged on 8/11/2013

18. THE END Sources: White, Sarah, and S. Stavropoulos. "Management of Endoleaks following Endovascular Aneurysm Repair." Seminars in Interventional Radiology 26.01 (2009): 033-38. Web.