67 year-old female with abdominal pain

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Doctor's Information

Name : Hamidreza
Family :Haghighatkhah
Affiliation : Radiology department,ShohadaTajrish Hospital,SBMU
Academic Degree: Associate professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Reza Pourghorban

Case Section

Interventional Radiology

Patient's Information

Gender : Female
Age : 67

Clinical Summary

A 67-year-old female with abdominal pain.

Imaging Findings

Aortic dissection is seen with extension to renal artery in left side(figure 1,2). Extension of dissection to right common iliac artery is present (figure 5). In angiography images aneurismal dissection is seen in abdominal aorta below the level of previously-placed stent for the same diagnosis in thoracic aorta, 12 months ago (figure 6). Catheterization of true lumen of aorta is done superiorly via the access of left subclavian artery and the stent is put distally via the access of right femoral artery (figure 7). The new stent is placed in distal aorta and common iliac arteries. As it is clear the false lumen of dissection fails to collapse (figures 8, 9). Type I endoleak is diagnosed due to extension of false lumen to the left renal artery. With deploying Balloon angioplasty at superior margin of the stent the false lumen of dissection is obstructed successfully (figure 10).

Differential Diagnosis

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Final Diagnosis

AAA, Dissection, EVAR, endoleak type 1

Discussion (Related Text)

Endovascular aneurysm repair is now commonly used to treat patients with amenable anatomy. The justification for the use of such a technique relates to observed short-term diminished morbidity, in contrast to open surgery . Using the Seldinger technique, sheaths and endografts are advanced into the aneurysm and secured in place. The exact deployment sequence depends on the graft used. A series of intraoperative angiograms followed by endograft component deployment is the typical sequence. Completion angiography with a pigtail catheter positioned just above the proximal anastomosis is performed to ensure successful aneurysm exclusion and no systemic flow within the aneurysm sac Endoleaks are defined as the persistence of blood flow outside the lumen of the endoluminal graft but within an aneurysm sac or adjacent vascular segment being treated by the graft. If flow into the aneurysm sac originates from around a stent graft attachment site (proximally or distally), it is called type I. This represents a failure of the stent graft to seal along the native arterial wall, creating a direct communication with the systemic arterial circulation. This type of endoleak is rare, occurring in 3-5% of patients. Balloons, stents, and extender cuffs are used for securing the malfunctioning segment to the arterial wall. Continued aortic neck dilatation after EVAR has been widely observed. This is a potential source of proximal type I endoleaks.

References

Stanley Baum, Michael J. Pentecost. Abrams' angiography: interventional radiology, 2nd ed. Philadelphia: LIPPINCOTT WILLIAMS & WILKINS 2006 p456, 460, And 462.