Successful treatment of type I endoleak of common iliac artery with balloon expandable stent (Palmaz XL stent) during endovascular aneurysm repair.
ABSTRACT Type 1 endoleak of common iliac artery (type I(b) endoleak) should be treated during endovascular aneurysm repair (EVAR). An 86-year-old female was diagnosed with abdominal aortic aneurysm measuring 6.6 cm in diameter and right internal iliac artery aneurysm measuring 4.0 cm in diameter. She underwent EVAR after right internal iliac artery embolization. There was type I(b) endoleak, which was repaired by balloon-expandable stent, Palmaz XL stent (Cordis). We report successful treatment of type I(b) endoleak with Palmaz XL stent, which may be considered as an alternative option for type I(b) endoleak after EVAR.
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ABSTRACT: Endovascular aneurysm repair (EVAR) of the abdominal aortic aneurysms is an attractive alternative to open surgery with significantly improved perioperative outcomes. However, EVAR is accompanied by a higher rate of graft-related complications and secondary interventions. Therefore, life-long surveillance and management of secondary treatment is essential for successful EVAR. Endoleaks are one of the most crucial problems after EVAR. Persistent endoleaks are classified into five types and its management depends on the type and severity. Most persistent endoleaks are detectable by contrast-enhanced computed tomography; however, in some cases, two different endoleak types may coexist. Determining whether an endoleak requires any treatment or not is an important consideration. Most if not all type I and III endoleaks require prompt and definitive secondary treatment. While type II endoleaks are most commonly encountered during follow-up, not all type II endoleaks require invasive treatment. When secondary treatment is required, it can be treated endovascularly in most cases, even if there is no endoleak. Following EVAR, due to the decompression of the sac, the integrity of the aneurysmal wall strength reduces. Therefore, sudden sac expansion/rupture may occur when an endoleak is encountered following a period of complete aneurysmal exclusion. If diagnosed promptly most late complications can be treated in a less invasive manner, but it could lead to catastrophic event if it is missed. Therefore, adequate and life-long radiographic follow-up is as important as the appropriate patient and device selection as well as the EVAR procedure itself.General Thoracic and Cardiovascular Surgery 10/2013;
Copyright © 2012, the Korean Surgical Society
J Korean Surg Soc 2012;82:59-62
Journal of the Korean Surgical Society
pISSN 2233-7903ㆍeISSN 2093-0488
Received June 14, 2011, Revised July 29, 2011, Accepted August 29, 2011
Correspondence to: Kee Chun Hong
Department of Surgery, Inha University Hospital, Inha University School of Medicine, 7-206 Sinheung-dong 3-ga, Jung-gu, Incheon 400-711,
Tel: ＋82-32-890-2738, Fax: ＋82-32-890-3097, E-mail: firstname.lastname@example.org
cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons
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distribution, and reproduction in any medium, provided the original work is properly cited.
Successful treatment of type I endoleak of common iliac
artery with balloon expandable stent (Palmaz XL stent)
during endovascular aneurysm repair
Jong Hyuk Ahn, Jang Yong Kim, Yong Sun Jeon1, Soon Gu Cho1, Jay K. Park2, Ki Jong Lee1,
Kee Chun Hong
Departments of Surgery, 1Radiology and 2International Healthcare Center, Inha University School of Medicine, Incheon, Korea
Type 1 endoleak of common iliac artery (type Ib endoleak) should be treated during endovascular aneurysm repair (EVAR).
An 86-year-old female was diagnosed with abdominal aortic aneurysm measuring 6.6 cm in diameter and right internal iliac
artery aneurysm measuring 4.0 cm in diameter. She underwent EVAR after right internal iliac artery embolization. There was
type Ib endoleak, which was repaired by balloon-expandable stent, Palmaz XL stent (Cordis). We report successful treatment
of type Ib endoleak with Palmaz XL stent, which may be considered as an alternative option for type Ib endoleak after EVAR.
Key Words: Abdominal aortic aneurysm, Endovascular procedure, Endoleak
Four to six percent of patients after endovascular aneur-
ysm repair (EVAR) develop type I endoleak that leaks at ei-
ther the proximal or distal sealing zone. Type I endoleak of
the distal sealing zone (type Ib endoleak) should be treated
during or after EVAR [1-3]. If endoleak is expected before
EVAR, embolization of the internal iliac artery with limb
extension to the external iliac artery, bypass or trans-
position of the internal iliac artery to the external iliac ar-
tery, or iliac bifurcated endograft has been used before or
during EVAR. At least, one internal iliac artery should be
saved during treatment . We report type Ib endoleak,
which was found and successfully treated with a Palmaz
XL stent (Cordis, Miami lakes, FL, USA) during EVAR
from our experience.
An 86-year-old woman presented with vague abdomi-
nal pain. She had been bed ridden for 5 years due to lum-
bar compression fractures. Though she had no history of
ischemic heart disease, a Thallium scan showed reversible
ischemia. Computed tomography (CT) revealed aneur-
ysms in the abdominal aorta and right internal iliac artery
Jong Hyuk Ahn, et al.
Fig. 1. Preoperative computed tomography of abdominal aortic aneurysm (AAA) revealed aortic neck was 24 mm in diameter, 20 mm in
length and 80 degrees in angulation (A). Aortic aneurysm was 66 × 74 mm in diameter (B). Right common iliac artery was 24 mm and left
common iliac artery was 22 mm in diameter (C). There was an aneurysm in right internal iliac artery, which was 40 mm in diameter (D, arrow).
Fig. 1E shows diagram of AAA.
measuring 66 mm and 40 mm in diameter (Fig. 1B, D). CT
showed that the aortic neck was 24 mm in diameter, 20 mm
in length and angulated by 80 degrees (Fig. 1A). The right
iliac artery was aneurysmal measuring 24 mm in diameter
and the left common iliac artery was 22 mm in diameter
(Fig. 1C). There was thrombus in the abdominal aortic
aneurysm. The patient underwent embolization of the
right internal iliac artery with 22 mm Amplatzer vascular
plug (AGA Medical, Plymouth, MN, USA) to control type
II endoleak from the right internal iliac artery. EVAR was
performed one week later. Under general anesthesia, both
femoral arteries were exposed by cutdown technique.
Three Zenith endografts (Cook Medical, Bloomington, IN,
USA) were deployed: 28 mm of the main body through the
right side, 24 mm left of the contralateral limb in the left
common iliac artery, and 10 mm right of the ipsilateral
limb extending to the right external iliac artery. The angio-
gram after EVAR showed persistent type Ib endoleak in the
left common iliac artery even after touch ballooning with
Coda balloon (Cook Medical) (Fig. 2A). Balloon-expanda-
ble stent, Palmaz XL was deployed (Fig. 2B) and the type Ib
endoleak in the left common iliac artery (Fig. 2C) was un-
der control. The Palmaz XL stent was manually mounted
with 16 mm Maxi Balloon (Cordis). After deployment of
the Palmaz XL stent, it was ballooned again with a Coda
balloon. Follow-up angiogram after completion showed
no endoleak. The patient was discharged without compli-
cations. Follow-up CT in 1 month showed no endoleak
When type Ib endoleak is expected before EVAR be-
cause of the iliac artery pathology, additional stent graft
cuff deployment, embolization of the internal iliac artery
Balloon expandable stent for treatment of type Ib endoleak
Fig. 3. There was no endoleak found in aortic neck (A, B), aneurysm (C, D) and iliac arteries (E, F) on computed tomography scan in 1 month
after endovascular aneurysm repair. Left common iliac artery was sealed by endograft and Palmaz XL stent (E). Right internal iliac artery was
occluded by Amplatzer vascular plug (F). Endograft and Palmaz XL stent in left common iliac artery were magnified (G).
Fig. 2. (A) Angiography showed type I endoleak in left common iliac artery. (B) Palmaz XL stent was deployed in left common iliac artery. (C)
Completion angiography showed disappearance of type I endoleak after Palmaz XL stent insertion.
with limb extension to the external iliac artery, transpo-
sition or bypass of the internal iliac artery to the external
iliac artery, or iliac bifurcated endograft may be consid-
ered as good alternatives [1,2]. However, treatment mo-
dality for type Ib endoleak after EVAR is especially limited,
or patients with high risk and those who already have had
embolization of the contralateral internal iliac artery.
Type Ib endoleak found at the time of the initial im-
plantation can be managed either by balloon dilatation or
placing an additional endograft across leaking graft junc-
tions, or may require extension of endograft distally in or-
der to obtain a complete seal [3,4]. The balloon angioplasty
did not seal the endoleak, and we think that the cause of
this endoleak was inadequate radial force of an endograft
limb in the left common iliac artery. Flare type stent can be
another option, but at the time of this case that stent was
not available in Korea. So, we used Palmaz XL balloon-ex-
pandable stent, which has strong radial force and provides
Jong Hyuk Ahn, et al.
a stronger and more persistent seal.
Arthurs et al.  recently reported that aortic neck re-
inforcement with Palmaz XL stent was still effective in
long-term follow-up when used for type Ia endoleak of
aortic neck. Malposition of a hand-mounted balloon-ex-
pandable stent during deployment is not an unusual com-
plication [6,7]. To prevent malposition and increase the ac-
curacy of stent deployment, the following techniques can
be beneficial [6,7]. First, the sheath provides a means to
control the sequence of the balloon expansion, and con-
sequently, stent deployment. The portion of the balloon-
stent apparatus expanding against the overlying sheath al-
so sandwiches the stent between the two providing addi-
tional stability. Second, the off-centered loading of the
stent onto the balloon leaves a larger portion of the prox-
imal (cranial) balloon exposed when the sheath is partially
drawn back. This allows for full expansion of only the
proximal portion of the balloon, which prevents proximal
stent migration. Again, the distal (caudal) sheath prevents
any distal stent migration.
Other methods to reduce maldeployment include using
a shorter stent and pre-expanding the proximal and distal
end of the balloon prior to placement within the sheath.
The partially inflated ends trap the stent and reduce the
tendency for one end to unevenly inflate causing “water-
melon seeding.” The drawbacks of this method include
compromised stent length and possible difficulty in in-
serting the partially deployed balloon and stent past the
proximal valve of the sheath .
This stent is the hand-mounted balloon-expandable
stent, which requires experience in use. And it costs
920,000 Won (Korean currency) in Korea which means ad-
ditional cost. But, recent data shows long-term stability af-
ter deployment during EVAR  and this seems to expand
indications of EVAR in clinical practices with good results.
In conclusion, we think that Palmaz XL balloon-ex-
pandable stent provides strong radial force and a more
persistent seal and can be an alternative option to achieve
tight sealing and control of type Ib endoleak.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article
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