eP464 - Use of Indocyanine Green Angiography in Laparoscopic Ligation of Inferior Mesenteric Artery for Type II Endoleak After Endovascular Aneurysm Repair

Purpose/Background: Endovascular aneurysm repair (EVAR) is the treatment of choice for nearly 80% of abdominal aortic aneurysm (AAA). However, the widespread adoption of EVAR has led to increased incidence of type II endoleak where the retrograde collateral blood from patent aortic side branches flows into the aneurysm sac. The most common feeder arteries are the inferior mesenteric artery (IMA) and lumbar arteries. Type II endoleak from IMA is traditionally treated with transarterial embolization (TAE) and less so from open or laparoscopic ligation, which is the technique that we will discuss in this case report. We aim to highlight the effectiveness of indocyanine green (ICG) angiography in aiding laparoscopic ligation of inferior mesenteric artery for EVAR type II endoleak.Methods/Interventions: In this case study, we describe a 70-year-old male, with a history of stroke, parkinson's disease, and hyperlipidemia, who was found to have an 9.8 cm infrarenal abdominal aortic aneurysm on Computed Tomography Angiography (CTA). Patient subsequently underwent EVAR. However, at 3-month follow up, he was found to have a type II endoleak with a 10 cm expanding aneurysm sac. The type II endoleak had retrograde filling from the inferior mesenteric artery (IMA) due to superior mesenteric artery collateralization via the marginal artery of the colon. Patient underwent a selective mesenteric angiogram for endovascular reintervention. Coil embolization of the IMA was attempted but unsuccessful.Results/Outcomes: The patient was taken to the operating room for laparoscopic high ligation of the IMA. Under laparoscopic visualization, the sigmoid colon was elevated to expose the IMA. The vessel was isolated, encircled and ligated with three clips. From there, ICG angiography was used to confirm both the perfusion to the colon and the exclusion of flow via the IMA to the aneurysm sac. The patient tolerated the procedure well and recovered on the floor. He was discharged home the next day. At 2-week follow up, there was no postoperative complications. At 2-month follow up, patient continued to do well and the aneurysm was found to have shrinked to 9.8 cm on CTA.Conclusion/

Discussion: Type II endoleak after EVAR of abdominal aortic aneurysm can be challenging to manage. In cases where embolization is unsuccessful in controlling the endoleak, laparoscopic ligation technique of IMA is a minimally invasive option with a high success rate. Prior reports of laparoscopic IMA ligation demonstrated technical success rate of 90% without any bowel ischemia complications or open conversion. In our study, we demonstrated that surgical ligation of IMA with ICG angiography further enhanced the safety profile. As the incidence of EVAR type II endoleak continues to rise, more studies are urgently needed to evaluate and compare the efficacy of the different endoleak treatments."Figure 1

Laparoscopic view of the infrarenal abdominal aortic aneurysm
Figure 2

Laparoscopic view of inferior mesenteric artery
Figure 3

Laparoscopical view of ligated IMA before indocyanine green (ICG) angiography
Figure 4

Laparoscopical view of ligated IMA after indocyanine green (ICG) angiography"