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Is Inferior Mesenteric Artery Embolization Indicated Prior to Endovascular Repair of Abdominal Aortic Aneurysm?

Open ArchivePublished:August 26, 2015DOI:https://doi.org/10.1016/j.ejvs.2015.06.116
      Type II endoleak is a common condition occurring after endovascular repair of abdominal aortic aneurysms (EVAR), and may result in aneurysm sac growth and/or rupture in a small number of patients. A prophylactic strategy of inferior mesenteric artery (IMA) embolization before EVAR has been advocated, however, the benefits of this strategy are controversial. A clinical vignette allows the authors to summarize the available data about this issue and discuss the possible benefits and risks of prophylactic IMA embolization before EVAR. The authors performed a meta-analysis of available data which showed that the pooled rate of type II endoleak after IMA embolization was 19.9% (95% CI 3.4–34.7%, I2 93%) whereas it was 41.4% (95% CI 30.4–52.3%, I2 76%) in patients without IMA embolization (5 studies including 596 patients: p < .0001, OR 0.369, 95% CI 0.22–0.61, I2 27%). Since treatment for type II endoleaks is needed in less than 20% of cases and this complication can be treated successfully in 60–70% of cases resulting in an aneurysm rupture risk of 0.9%, these data indicate that embolization of patent IMA may be of no benefit in patients undergoing EVAR.

      Keywords

      A 67 year old man presents with a growing infrarenal abdominal aortic aneurysm. He has been a heavy smoker, has a history of myocardial infarction 2 years ago, and suffers from moderate renal impairment. The pre-operative CT angiogram reveals a favorable anatomy for EVAR but shows a relatively large and patent inferior mesenteric artery. Should I coil this artery during or before EVAR?
      Type II endoleak is a common condition occurring after endovascular repair of abdominal aortic aneurysms (EVAR). It is the result of retrograde blood flow into the aneurysm sac from patent aortic vessels such as the inferior mesenteric artery (IMA), the lumbar arteries, and the median sacral artery through collateral circulation.
      • Güntner O.
      • Zeman F.
      • Wohlgemuth W.A.
      • Heiss P.
      • Jung E.M.
      • Wiggermann P.
      • et al.
      Inferior mesenteric arterial type II endoleaks after endovascular repair of abdominal aortic aneurysm: are they predictable?.
      • Fujita S.
      • Resch T.A.
      • Kristmundsson T.
      • Sonesson B.
      • Lindblad B.
      • Malina M.
      Impact of intrasac thrombus and a patent inferior mesenteric artery on EVAR outcome.
      • Coscas R.
      • Greenberg R.K.
      • Pfaff K.
      Embolization of a type 2 endoleak through catheterization of a hypogastric branched stent graft.
      A patent IMA is considered a major source of type II endoleak.
      • Güntner O.
      • Zeman F.
      • Wohlgemuth W.A.
      • Heiss P.
      • Jung E.M.
      • Wiggermann P.
      • et al.
      Inferior mesenteric arterial type II endoleaks after endovascular repair of abdominal aortic aneurysm: are they predictable?.
      • Zhou W.
      • Blay Jr., E.
      • Varu V.
      • Ali S.
      • Jin M.Q.
      • Sun L.
      • et al.
      Outcome and clinical significance of delayed endoleaks after endovascular aneurysm repair.
      The number of additional patent aortic branches is also associated with an increased risk of such endoleaks.
      • Güntner O.
      • Zeman F.
      • Wohlgemuth W.A.
      • Heiss P.
      • Jung E.M.
      • Wiggermann P.
      • et al.
      Inferior mesenteric arterial type II endoleaks after endovascular repair of abdominal aortic aneurysm: are they predictable?.
      • Otsu M.
      • Ishizaka T.
      • Watanabe M.
      • Hori T.
      • Kohno H.
      • Ishida K.
      • et al.
      Analysis of anatomical risk factors for persistent type II endoleaks following endovascular abdominal aortic aneurysm repair using CT angiography.
      Type II endoleak is considered the least severe type of endoleak occurring after EVAR. Still, in a small number of patients, type II endoleak may result in aneurysm sac growth and/or rupture. Since the treatment of this endoleak is sometimes technically difficult with suboptimal results,
      • Muthu C.
      • Maani J.
      • Plank L.D.
      • Holden A.
      • Hill A.
      Strategies to reduce the rate of type II endoleaks: routine intra-operative embolization of the inferior mesenteric artery and thrombin injection into the aneurysm sac.
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      a prophylactic strategy of IMA embolization before EVAR has been advocated.
      The incidence of type II endoleak detected at computed tomography after EVAR ranges from 3% to 25%,
      • Sidloff D.A.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak after endovascular aneurysm repair.
      • Abularrage C.J.
      • Crawford R.S.
      • Conrad M.F.
      • Lee H.
      • Kwolek C.J.
      • Brewster D.C.
      • et al.
      Pre-operative variables predict persistent type 2 endoleak after endovascular aneurysm repair.
      • Fukuda T.
      • Matsuda H.
      • Sanda Y.
      • Morita Y.
      • Minatoya K.
      • Kobayashi J.
      • et al.
      CT findings of risk factors for persistent type II endoleak from inferior mesenteric artery to determine indicators of pre-operative IMA embolization.
      and it is likely to be higher when magnetic resonance imaging is used.
      • Cantisani V.
      • Ricci P.
      • Grazhdani H.
      • Napoli A.
      • Fanelli F.
      • Catalano C.
      • et al.
      Prospective comparative analysis of colour-Doppler ultrasound, contrast enhanced ultrasound, computed tomography and magnetic resonance in detecting endoleak after endovascular abdominal aortic aneurysm repair.
      Between 50% and 80%
      • Jones J.E.
      • Atkins M.D.
      • Brewster D.C.
      • Chung T.K.
      • Kwolek C.J.
      • LaMuraglia G.M.
      • et al.
      Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.
      • Sidloff D.A.
      • Gokani V.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak: conservative management is a safe strategy.
      of such leaks resolve spontaneously within the first 6 months of the operation and no treatment is indicated. However, a minority of type II endoleaks persist or others may appear later on, and this may cause concern regarding their impact on the fate of the aneurysm sac.
      • Zhou W.
      • Blay Jr., E.
      • Varu V.
      • Ali S.
      • Jin M.Q.
      • Sun L.
      • et al.
      Outcome and clinical significance of delayed endoleaks after endovascular aneurysm repair.

      Prognostic Impact of Type II Endoleak

      Studies regarding the significance of type II endoleak have shown contradictory results. Some studies have shown that type II endoleaks are associated with a benign course.
      • Hajibandeh S.
      • Ahmad N.
      • Antoniou G.A.
      • Torella F.
      Is intervention better than surveillance in patients with type 2 endoleak post endovascular abdominal aortic aneurysm repair?.
      • Baum R.A.
      • Carpenter J.P.
      • Cope C.
      • Golden M.A.
      • Velazquez O.C.
      • Neschis D.G.
      • et al.
      Aneurysm sac pressure measurements after endovascular repair of abdominal aortic aneurysms.
      However, most studies are in agreement that type II endoleak may result in persistently elevated intra-sac pressure and failure of aneurysm sac shrinkage.
      • Baum R.A.
      • Carpenter J.P.
      • Cope C.
      • Golden M.A.
      • Velazquez O.C.
      • Neschis D.G.
      • et al.
      Aneurysm sac pressure measurements after endovascular repair of abdominal aortic aneurysms.
      A few studies concluded that persistent type II endoleak is associated with adverse outcomes such as aneurysm sac growth and rupture and therefore requires re-intervention.
      • Zhou W.
      • Blay Jr., E.
      • Varu V.
      • Ali S.
      • Jin M.Q.
      • Sun L.
      • et al.
      Outcome and clinical significance of delayed endoleaks after endovascular aneurysm repair.
      • Jones J.E.
      • Atkins M.D.
      • Brewster D.C.
      • Chung T.K.
      • Kwolek C.J.
      • LaMuraglia G.M.
      • et al.
      Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.
      In a recent meta-analysis of 32 studies including 21,744 patients, type II endoleak after EVAR was detected in 10.2% of patients.
      • Sidloff D.A.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak after endovascular aneurysm repair.
      About 35% of these endoleaks resolved spontaneously. Three hundred and ninety three (26%) interventions for type II endoleak were performed with a success rate of 71.5%. Fourteen patients (0.9%) with isolated type II endoleak had ruptured abdominal aortic aneurysm, six of them without any sign of aneurysm sac growth. Another meta-analysis
      • Karthikesalingam A.
      • Thrumurthy S.G.
      • Jackson D.
      • Phd E.C.
      • Sayers R.D.
      • Loftus I.M.
      • et al.
      Current evidence is insufficient to define an optimal threshold for intervention in isolated type II endoleak after endovascular aneurysm repair.
      was not able to define a threshold for treatment of type II endoleak as the aggressive treatment of type II endoleak not associated with sac expansion did not provide better results than a more conservative strategy (intervention only in cases of type II endoleak with sac expansion > 5 mm or persistent type II endoleak for > 12 months). No aneurysm rupture occurred in this pooled series. However, type II endoleak associated with an aneurysm sac growth ≥ 10 mm is considered an indication for endovascular, laparoscopic or open repair.
      • Moll F.L.
      • Powell J.T.
      • Fraedrich G.
      • Verzini F.
      • Haulon S.
      • Waltham M.
      • et al.
      Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery.

      Impact of Inferior Mesenteric Embolization Prior to Evar in Preventing Type II Endoleak

      Although EVAR has been performed for almost three decades, there are only five studies adequately comparing the outcome of IMA embolization with a conservative strategy.
      • Axelrod D.J.
      • Lookstein R.A.
      • Guller J.
      • Nowakowski F.S.
      • Ellozy S.
      • Carroccio A.
      • et al.
      Inferior mesenteric artery embolization before endovascular aneurysm repair: technique and initial results.
      • Burbelko M.
      • Kalinowski M.
      • Heverhagen J.T.
      • Piechowiak E.
      • Kiessling A.
      • Figiel J.
      • et al.
      Prevention of type II endoleak using the AMPLATZER vascular plug before endovascular aneurysm repair.
      • Müller-Wille R.
      • Uller W.
      • Gössmann H.
      • Heiss P.
      • Wiggermann P.
      • Dollinger M.
      • et al.
      Inferior mesenteric artery embolization before endovascular aortic aneurysm repair using Amplatzer vascular plug type 4.
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Matsi P.
      • Mäkinen K.
      • Ylönen K.
      • et al.
      Inferior mesenteric artery embolization before endovascular repair of an abdominal aortic aneurysm: effect on type II endoleak and aneurysm shrinkage.
      • Ward T.J.
      • Cohen S.
      • Fischman A.M.
      • Kim E.
      • Nowakowski F.S.
      • Ellozy S.H.
      • et al.
      Pre-operative inferior mesenteric artery embolization before endovascular aneurysm repair: decreased incidence of type II endoleak and aneurysm sac enlargement with 24-month follow up.
      The results of these series have been pooled here using the random effects method. Statistical analysis was performed using Open meta-analysis statistical software (http://www.cebm.brown.edu/open_meta). These five studies reported on 246 patients who underwent IMA embolization with or without embolization of patent lumbar arteries and their outcome was compared with that of 350 patients with patent IMA and who did not undergo prophylactic embolization of the aortic branches. Two studies performed IMA embolization with Amplazer
      • Burbelko M.
      • Kalinowski M.
      • Heverhagen J.T.
      • Piechowiak E.
      • Kiessling A.
      • Figiel J.
      • et al.
      Prevention of type II endoleak using the AMPLATZER vascular plug before endovascular aneurysm repair.
      • Müller-Wille R.
      • Uller W.
      • Gössmann H.
      • Heiss P.
      • Wiggermann P.
      • Dollinger M.
      • et al.
      Inferior mesenteric artery embolization before endovascular aortic aneurysm repair using Amplatzer vascular plug type 4.
      and the others by coiling.
      • Axelrod D.J.
      • Lookstein R.A.
      • Guller J.
      • Nowakowski F.S.
      • Ellozy S.
      • Carroccio A.
      • et al.
      Inferior mesenteric artery embolization before endovascular aneurysm repair: technique and initial results.
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Matsi P.
      • Mäkinen K.
      • Ylönen K.
      • et al.
      Inferior mesenteric artery embolization before endovascular repair of an abdominal aortic aneurysm: effect on type II endoleak and aneurysm shrinkage.
      • Ward T.J.
      • Cohen S.
      • Fischman A.M.
      • Kim E.
      • Nowakowski F.S.
      • Ellozy S.H.
      • et al.
      Pre-operative inferior mesenteric artery embolization before endovascular aneurysm repair: decreased incidence of type II endoleak and aneurysm sac enlargement with 24-month follow up.
      In a few cases, embolization of lumbar arteries was performed as well. The embolization procedure had a success rate of 98.4% (95% CI 96.3–100%). The rate of type II endoleak after IMA embolization was 19.9% (95% CI 3.4–34.7%, I2 93%) whereas it was 41.4% (95% CI 30.4–52.3%, I2 76%) in patients without IMA embolization (p < .0001, OR 0.369, 95% CI 0.222–0.613, I2 27%) (Fig. 1). Lumbar arteries were responsible for type II endoleak in a few patients.
      • Axelrod D.J.
      • Lookstein R.A.
      • Guller J.
      • Nowakowski F.S.
      • Ellozy S.
      • Carroccio A.
      • et al.
      Inferior mesenteric artery embolization before endovascular aneurysm repair: technique and initial results.
      Four studies
      • Axelrod D.J.
      • Lookstein R.A.
      • Guller J.
      • Nowakowski F.S.
      • Ellozy S.
      • Carroccio A.
      • et al.
      Inferior mesenteric artery embolization before endovascular aneurysm repair: technique and initial results.
      • Burbelko M.
      • Kalinowski M.
      • Heverhagen J.T.
      • Piechowiak E.
      • Kiessling A.
      • Figiel J.
      • et al.
      Prevention of type II endoleak using the AMPLATZER vascular plug before endovascular aneurysm repair.
      • Müller-Wille R.
      • Uller W.
      • Gössmann H.
      • Heiss P.
      • Wiggermann P.
      • Dollinger M.
      • et al.
      Inferior mesenteric artery embolization before endovascular aortic aneurysm repair using Amplatzer vascular plug type 4.
      • Ward T.J.
      • Cohen S.
      • Fischman A.M.
      • Kim E.
      • Nowakowski F.S.
      • Ellozy S.H.
      • et al.
      Pre-operative inferior mesenteric artery embolization before endovascular aneurysm repair: decreased incidence of type II endoleak and aneurysm sac enlargement with 24-month follow up.
      reported on the number of patients who required re-intervention for type II endoleak and this was significantly lower after IMA embolization (1.2% vs. 13.4%, p < .0001, OR 0.091, 95% CI 0.027–0.301, I2 0%). However, the threshold for intervention varied significantly between studies. Two studies reported on aneurysm related mortality, which was nil in both.
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Matsi P.
      • Mäkinen K.
      • Ylönen K.
      • et al.
      Inferior mesenteric artery embolization before endovascular repair of an abdominal aortic aneurysm: effect on type II endoleak and aneurysm shrinkage.
      • Ward T.J.
      • Cohen S.
      • Fischman A.M.
      • Kim E.
      • Nowakowski F.S.
      • Ellozy S.H.
      • et al.
      Pre-operative inferior mesenteric artery embolization before endovascular aneurysm repair: decreased incidence of type II endoleak and aneurysm sac enlargement with 24-month follow up.
      One patient developed mesenteric ischemia after IMA embolization and died.
      • Ward T.J.
      • Cohen S.
      • Fischman A.M.
      • Kim E.
      • Nowakowski F.S.
      • Ellozy S.H.
      • et al.
      Pre-operative inferior mesenteric artery embolization before endovascular aneurysm repair: decreased incidence of type II endoleak and aneurysm sac enlargement with 24-month follow up.
      No homogeneous data were reported on the rate of growth of the aneurysm sac in these studies. In one study,
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Matsi P.
      • Mäkinen K.
      • Ylönen K.
      • et al.
      Inferior mesenteric artery embolization before endovascular repair of an abdominal aortic aneurysm: effect on type II endoleak and aneurysm shrinkage.
      the overall linearized aneurysm shrinkage rate was 1.4 ± 3.8 mm per year in the IMA embolization group and 1.7 ± 2.4 mm per year in the control group (p < .72).
      Figure thumbnail gr1
      Figure 1Forest plot showing the impact of pre-operative inferior mesenteric artery (IMA) embolization versus conservative treatment on the development of type II endoleak in patients with patent IMA undergoing endovascular repair of abdominal aortic aneurysm.

      Diameter of the Inferior Mesenteric Artery and Occurrence of Type II Endoleak

      The impact of the size of IMA on the occurrence of type II endoleak is a matter of intense debate. Fukuda et al.
      • Fukuda T.
      • Matsuda H.
      • Sanda Y.
      • Morita Y.
      • Minatoya K.
      • Kobayashi J.
      • et al.
      CT findings of risk factors for persistent type II endoleak from inferior mesenteric artery to determine indicators of pre-operative IMA embolization.
      observed that the diameter of the proximal IMA was larger than 2.5 mm in 24% (26/106) of patients without type II endoleak, in 50% of those with transient endoleak (5/10), and 100% (5/5) in patients with persistent endoleak. In multivariate analysis, the absence of stenosis of the IMA at its orifice was more likely to be a significant factor of persistent type II endoleak (p = .0003), and thrombus at the orifice of the IMA was a negative predictor of persistent type II endoleak (p = 0.043).
      • Fukuda T.
      • Matsuda H.
      • Sanda Y.
      • Morita Y.
      • Minatoya K.
      • Kobayashi J.
      • et al.
      CT findings of risk factors for persistent type II endoleak from inferior mesenteric artery to determine indicators of pre-operative IMA embolization.
      Otsu and colleagues
      • Otsu M.
      • Ishizaka T.
      • Watanabe M.
      • Hori T.
      • Kohno H.
      • Ishida K.
      • et al.
      Analysis of anatomical risk factors for persistent type II endoleaks following endovascular abdominal aortic aneurysm repair using CT angiography.
      confirmed these findings and showed that an IMA diameter > 2.5 mm along with each additional patent lumbar artery ≥ 1.9 mm were predictors of permanent type II endoleak. Similarly, Müller-Wille and colleagues
      • Müller-Wille R.
      • Schötz S.
      • Zeman F.
      • Uller W.
      • Güntner O.
      • Pfister K.
      • et al.
      CT features of early type II endoleaks after endovascular repair of abdominal aortic aneurysms help predict aneurysm sac enlargement.
      observed that patients without complex IMA and lumbar artery type II endoleak in whom the largest feeding and/or draining artery was larger than 3.8 mm, and patients with a complex IMA type II endoleak in whom the largest feeding and/or draining artery was larger than 2.2 mm were at high risk for aneurysm sac enlargement.
      Another study showed the significant association between the diameter of the IMA and the occurrence of type II endoleak.
      • Löwenthal D.
      • Herzog L.
      • Rogits B.
      • Bulla K.
      • Weston S.
      • Meyer F.
      • et al.
      Identification of predictive CT angiographic factors in the development of high risk type 2 endoleaks after endovascular aneurysm repair in patients with infrarenal aortic aneurysms.
      However, multivariate analysis showed that the number and diameter of patent lumbar arteries were the only predictors of permanent type II endoleak requiring treatment.
      • Löwenthal D.
      • Herzog L.
      • Rogits B.
      • Bulla K.
      • Weston S.
      • Meyer F.
      • et al.
      Identification of predictive CT angiographic factors in the development of high risk type 2 endoleaks after endovascular aneurysm repair in patients with infrarenal aortic aneurysms.
      Other studies confirmed the lack of association between the diameter of the IMA and the development of type II endoleak
      • Güntner O.
      • Zeman F.
      • Wohlgemuth W.A.
      • Heiss P.
      • Jung E.M.
      • Wiggermann P.
      • et al.
      Inferior mesenteric arterial type II endoleaks after endovascular repair of abdominal aortic aneurysm: are they predictable?.
      • Zhou W.
      • Blay Jr., E.
      • Varu V.
      • Ali S.
      • Jin M.Q.
      • Sun L.
      • et al.
      Outcome and clinical significance of delayed endoleaks after endovascular aneurysm repair.
      and rather suggested that the number of patent lumbar arteries was a risk factor for such an endoleak.
      • Güntner O.
      • Zeman F.
      • Wohlgemuth W.A.
      • Heiss P.
      • Jung E.M.
      • Wiggermann P.
      • et al.
      Inferior mesenteric arterial type II endoleaks after endovascular repair of abdominal aortic aneurysm: are they predictable?.

      Potential Adverse Events Associated with Inferior Mesenteric Artery Embolization

      A few serious complications have been reported after embolization of the IMA. Post-operative death secondary to colonic ischemia has been reported as a result of catheter directed embolization of the IMA prior to EVAR
      • Muthu C.
      • Maani J.
      • Plank L.D.
      • Holden A.
      • Hill A.
      Strategies to reduce the rate of type II endoleaks: routine intra-operative embolization of the inferior mesenteric artery and thrombin injection into the aneurysm sac.
      • Ward T.J.
      • Cohen S.
      • Fischman A.M.
      • Kim E.
      • Nowakowski F.S.
      • Ellozy S.H.
      • et al.
      Pre-operative inferior mesenteric artery embolization before endovascular aneurysm repair: decreased incidence of type II endoleak and aneurysm sac enlargement with 24-month follow up.
      • Miller A.
      • Marotta M.
      • Scordi-Bello I.
      • Tammaro Y.
      • Marin M.
      • Divino C.
      Ischemic colitis after endovascular aortoiliac aneurysm repair: a 10 year retrospective study.
      and for treatment of type II endoleak.
      • Bush R.L.
      • Lin P.H.
      • Ronson R.S.
      • Conklin B.S.
      • Martin L.G.
      • Lumsden A.B.
      Colonic necrosis subsequent to catheter-directed thrombin embolization of the inferior mesenteric artery via the superior mesenteric artery: a complication in the management of a type II endoleak.
      Overall, the incidence of mesenteric ischemia in extremely low.
      • Ward T.J.
      • Cohen S.
      • Fischman A.M.
      • Kim E.
      • Nowakowski F.S.
      • Ellozy S.H.
      • et al.
      Pre-operative inferior mesenteric artery embolization before endovascular aneurysm repair: decreased incidence of type II endoleak and aneurysm sac enlargement with 24-month follow up.
      Aortitis has been observed after percutaneous endovascular coil embolization prior to EVAR.
      • Dick F.
      • Diehm N.
      • Gerber M.
      • Widmer M.K.
      • Do D.D.
      • Triller J.
      • et al.
      Aortitis following percutaneous aortic side branch embolization prior to endovascular repair of infrarenal aortic aneurysm.
      Since IMA embolization is associated with a significantly increased use of contrast agent,
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Matsi P.
      • Mäkinen K.
      • Ylönen K.
      • et al.
      Inferior mesenteric artery embolization before endovascular repair of an abdominal aortic aneurysm: effect on type II endoleak and aneurysm shrinkage.
      the potential risk of acute kidney injury should be considered in the decision making process in patients with decreased renal function.

      Cost related issues with inferior mesenteric artery embolization

      The cost of pre-operative embolization with an Amplatzer device has been estimated to be about 300 euros and of coils ranging from 360 to 600 euros.
      • Burbelko M.
      • Kalinowski M.
      • Heverhagen J.T.
      • Piechowiak E.
      • Kiessling A.
      • Figiel J.
      • et al.
      Prevention of type II endoleak using the AMPLATZER vascular plug before endovascular aneurysm repair.
      However, considering the current clinical practice in which type II endoleaks are actively treated only in case of aneurysm growth, it is evident that routine pre-operative IMA embolization is not cost-effective.
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Matsi P.
      • Mäkinen K.
      • Ylönen K.
      • et al.
      Inferior mesenteric artery embolization before endovascular repair of an abdominal aortic aneurysm: effect on type II endoleak and aneurysm shrinkage.

      Clinical Decision in this Patient

      The present patient is rather young, but has a history of myocardial infarction and of moderate renal failure, which may increase his operative and late mortality risk.
      • Löwenthal D.
      • Herzog L.
      • Rogits B.
      • Bulla K.
      • Weston S.
      • Meyer F.
      • et al.
      Identification of predictive CT angiographic factors in the development of high risk type 2 endoleaks after endovascular aneurysm repair in patients with infrarenal aortic aneurysms.
      • Miller A.
      • Marotta M.
      • Scordi-Bello I.
      • Tammaro Y.
      • Marin M.
      • Divino C.
      Ischemic colitis after endovascular aortoiliac aneurysm repair: a 10 year retrospective study.
      • Bush R.L.
      • Lin P.H.
      • Ronson R.S.
      • Conklin B.S.
      • Martin L.G.
      • Lumsden A.B.
      Colonic necrosis subsequent to catheter-directed thrombin embolization of the inferior mesenteric artery via the superior mesenteric artery: a complication in the management of a type II endoleak.
      • Dick F.
      • Diehm N.
      • Gerber M.
      • Widmer M.K.
      • Do D.D.
      • Triller J.
      • et al.
      Aortitis following percutaneous aortic side branch embolization prior to endovascular repair of infrarenal aortic aneurysm.
      • Hollier L.H.
      • Plate G.
      • O'Brien P.C.
      • Kazmier F.J.
      • Gloviczki P.
      • Pairolero P.C.
      • et al.
      Late survival after abdominal aortic aneurysm repair: influence of coronary artery disease.
      • Mooney J.F.
      • Ranasinghe I.
      • Chow C.K.
      • Perkovic V.
      • Barzi F.
      • Zoungas S.
      • et al.
      Pre-operative estimates of glomerular filtration rate as predictors of outcome after surgery: a systematic review and meta-analysis.
      • Tonelli M.
      • Wiebe N.
      • Culleton B.
      • House A.
      • Rabbat C.
      • Fok M.
      • et al.
      Chronic kidney disease and mortality risk: a systematic review.
      He has been a heavy smoker and this may further decrease his life expectancy.
      • van Kruijsdijk R.C.
      • van der Graaf Y.
      • Koffijberg H.
      • Jan de Borst G.
      • Nathoe H.M.
      • Jaap Kappelle L.
      • et al.
      Cause specific mortality and years of life lost in patients with different manifestations of vascular disease.
      If it is assumed that his moderate renal insufficiency is equivalent to a creatinine serum level > 150 μmol/L, the Glasgow Aneurysm Score would be 88. According to the Eurostar registry data, the 30 day mortality risk of this patient would be about 5% and his 6 year survival would be about 60%.
      • Biancari F.
      • Hobo R.
      • Juvonen T.
      Glasgow aneurysm score predicts survival after endovascular stenting of abdominal aortic aneurysm in patients from the EUROSTAR registry.
      Such a high operative risk suggests that he most certainly would benefit from a straightforward EVAR without IMA embolization. This strategy would also prevent any further risk of acute kidney injury possibly associated with the use of a larger amount of contrast.
      There are a few data showing that smoking habit is associated with a lower risk of type II endoleak after EVAR.
      • El Batti S.
      • Cochennec F.
      • Roudot-Thoraval F.
      • Becquemin J.P.
      Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition.
      • Koole D.
      • Moll F.L.
      • Buth J.
      • Hobo R.
      • Zandvoort H.
      • Pasterkamp G.
      • et al.
      The influence of smoking on endovascular abdominal aortic aneurysm repair.
      • Warrier R.
      • Miller R.
      • Bond R.
      • Robertson I.K.
      • Hewitt P.
      • Scott A.
      Risk factors for type II endoleaks after endovascular repair of abdominal aortic aneurysms.
      Such a lower risk of endoleak can be related to the decreased perfusion of the IMA and lumbar arteries in previous and current smokers compared with non-smokers.
      • Koole D.
      • Moll F.L.
      • Buth J.
      • Hobo R.
      • Zandvoort H.
      • Pasterkamp G.
      • et al.
      The influence of smoking on endovascular abdominal aortic aneurysm repair.
      Indeed, universal atherosclerosis in heavy smokers may affect the visceral arteries and impair the retrograde collateral circulation to the aneurysm sac. Since this patient has been a heavy smoker, it may be expected that his risk of developing a type II endoleak secondary to a patent IMA is significantly reduced.
      Pooled analysis of available data indicates that IMA embolization is associated with significantly lower risk of type II endoleak, but the pooled rate of this event is still about 20% among these patients and other aortic branches may be responsible for endoleak. Therefore, type II endoleak cannot be prevented in all patients solely by IMA embolization. Indeed, large lumbar arteries are associated with the occurrence of type II endoleak,
      • Marchiori A.
      • von Ristow A.
      • Guimaraes M.
      • Schönholz C.
      • Uflacker R.
      Predictive factors for the development of type II endoleaks.
      and their contribution may be more significant than the IMA.
      • Fujita S.
      • Resch T.A.
      • Kristmundsson T.
      • Sonesson B.
      • Lindblad B.
      • Malina M.
      Impact of intrasac thrombus and a patent inferior mesenteric artery on EVAR outcome.
      • Löwenthal D.
      • Herzog L.
      • Rogits B.
      • Bulla K.
      • Weston S.
      • Meyer F.
      • et al.
      Identification of predictive CT angiographic factors in the development of high risk type 2 endoleaks after endovascular aneurysm repair in patients with infrarenal aortic aneurysms.
      Therefore, accurate imaging evaluation of the lumbar arteries is needed to better estimate the real value of IMA embolization when a large number of lumbar arteries are patent.
      Since treatment for type II endoleaks is needed in less than 20% of cases and this complication can be treated successfully in 60–70% of cases,
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Matsi P.
      • Mäkinen K.
      • Ylönen K.
      • et al.
      Inferior mesenteric artery embolization before endovascular repair of an abdominal aortic aneurysm: effect on type II endoleak and aneurysm shrinkage.
      resulting in an aneurysm rupture risk of 0.9%,
      • Sidloff D.A.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak after endovascular aneurysm repair.
      it is believed that embolization of patent IMA before EVAR is not indicated in this high risk patient.

      Conflict of Interest

      None.

      Funding

      None.

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