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Aortic morphometry at endograft position as assessed by 3D image analysis affects risk of type I endoleak formation after TEVAR

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The purpose of this study was to identify morphologic factors affecting type I endoleak formation and bird-beak configuration after thoracic endovascular aortic repair (TEVAR).


Computed tomography (CT) data of 57 patients (40 males; median age, 66 years) undergoing TEVAR for thoracic aortic aneurysm (34 TAA, 19 TAAA) or penetrating aortic ulcer (n = 4) between 2001 and 2010 were retrospectively reviewed. In 28 patients, the Gore TAG® stent-graft was used, followed by the Medtronic Valiant® in 16 cases, the Medtronic Talent® in 8, and the Cook Zenith® in 5 cases. Proximal landing zone (PLZ) was in zone 1 in 13, zone 2 in 13, zone 3 in 23, and zone 4 in 8 patients. In 14 patients (25 %), the procedure was urgent or emergent. In each case, pre- and postoperative CT angiography was analyzed using a dedicated image processing workstation and complimentary in-house developed software based on a 3D cylindrical intensity model to calculate aortic arch angulation and conicity of the landing zones (LZ).


Primary type Ia endoleak rate was 12 % (7/57) and subsequent re-intervention rate was 86 % (6/7). Left subclavian artery (LSA) coverage (p = 0.036) and conicity of the PLZ (5.9 vs. 2.6 mm; p = 0.016) were significantly associated with an increased type Ia endoleak rate. Bird-beak configuration was observed in 16 patients (28 %) and was associated with a smaller radius of the aortic arch curvature (42 vs. 65 mm; p = 0.049). Type Ia endoleak was not associated with a bird-beak configuration (p = 0.388). Primary type Ib endoleak rate was 7 % (4/57) and subsequent re-intervention rate was 100 %. Conicity of the distal LZ was associated with an increased type Ib endoleak rate (8.3 vs. 2.6 mm; p = 0.038).


CT-based 3D aortic morphometry helps to identify risk factors of type I endoleak formation and bird-beak configuration during TEVAR. These factors were LSA coverage and conicity within the landing zones for type I endoleak formation and steep aortic angulation for bird-beak configuration.

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  1. Patel HJ, Williams DM, Upchurch GR Jr, Shillingford MS, Dasika NL, Proctor MC, Deeb GM (2006) Long-term results from a 12-year experience with endovascular therapy for thoracic aortic disease. Ann Thorac Surg 82:2147–2153

    Article  PubMed  Google Scholar 

  2. Glade GJ, Vahl AC, Wisselink W, Linsen MA, Balm R (2005) Mid-term survival and costs of treatment of patients with descending thoracic aortic aneurysms; endovascular vs. open repair: a case-control study. Eur J Vasc Endovasc Surg 29:28–34

    Article  CAS  PubMed  Google Scholar 

  3. Stone DH, Brewster DC, Kwolek CJ, Lamuraglia GM, Conrad MF, Chung TK, Cambria RP (2006) Stent-graft versus open-surgical repair of the thoracic aorta: mid-term results. J Vasc Surg 44:1188–1197

    Article  PubMed  Google Scholar 

  4. Geisbüsch P, Hoffmann S, Kotelis D, Able T, Hyhlik-Dürr A, Böckler D (2011) Reinterventions during midterm follow-up after endovascular treatment of thoracic aortic disease. J Vasc Surg 53:1528–33

    Article  PubMed  Google Scholar 

  5. Ueda T, Fleischmann D, Dake MD, Rubin GD, Sze DY (2010) Incomplete endograft apposition to the aortic arch: bird-beak configuration increases risk of endoleak formation after thoracic endovascular aortic repair. Radiology 255:645–652

    Article  PubMed  Google Scholar 

  6. Sze DY, van den Bosch MA, Dake MD, Miller DC, Hofmann LV, Varghese R, Malaisrie SC, van der Starre PJ, Rosenberg J, Mitchell RS (2009) Factors portending endoleak formation after thoracic aortic stent-graft repair of complicated aortic dissection. Circ Cardiovasc Interv 2:105–12

    Article  PubMed  Google Scholar 

  7. Morales JP, Greenberg RK, Lu Q, Cury M, Hernandez AV, Mohabbat W, Moon MC, Morales CA, Bathurst S, Schoenhagen P (2008) Endoleaks following endovascular repair of thoracic aortic aneurysm: etiology and outcomes. J Endovasc Ther 15:631–8

    Article  PubMed  Google Scholar 

  8. Fillinger MF, Greenberg RK, McKinsey JF, Elliot L, Chaikof EL (2010) Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg 52:1022–33

    Article  PubMed  Google Scholar 

  9. Kotelis D, Geisbüsch P, Hinz U, Hyhlik-Dürr A, von Tengg-Kobligk H, Allenberg JR, Böckler D (2009) Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg 50:1285–92

    Article  PubMed  Google Scholar 

  10. Lee WA (2007) Endovascular abdominal aortic aneurysm sizing and case planning using the TeraRecon Aquarius workstation. Vasc Endovascular Surg 41:61–67

    Article  PubMed  Google Scholar 

  11. Wörz S, Rohr K (2007) Segmentation and quantification of human vessels using a 3-D cylindrical intensity model. IEEE Trans Image Process 16:1994–2004

    Article  PubMed  Google Scholar 

  12. Wörz S, von Tengg-Kobligk H, Henninger V, Rengier F, Schumacher H, Böckler D, Kauczor HU, Rohr K (2010) 3-D quantification of the aortic arch morphology in 3-D CTA data for endovascular aortic repair. IEEE Trans Biomed Eng 57:2359–2368

    Article  PubMed  Google Scholar 

  13. White GH, Yu W, May J, Chaufour X, Stephen MS (1997) Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, incidence, diagnosis, and management. J Endovasc Surg 4:152–68

    Article  CAS  PubMed  Google Scholar 

  14. Ueda T, Takaoka H, Raman B, Rosenberg J, Rubin GD (2011) Impact of quantitatively determined native thoracic aortic tortuosity on endoleak development after thoracic endovascular aortic repair. AJR Am J Roentgenol 197:1140–6

    Article  Google Scholar 

  15. Nakatamari H, Ueda T, Ishioka F, Raman B, Kurihara K, Rubin GD, Ito H, Sze DY (2011) Discriminant analysis of native thoracic aortic curvature: risk prediction for endoleak formation after thoracic endovascular aortic repair. J Vasc Interv Radiol 22:974–979

    Article  PubMed  Google Scholar 

  16. Alberta HB, Secor JL, Smits TC, Farber MA, Jordan WD, Matsumura JS (2013) Differences in aortic arch radius of curvature, neck size, and taper in patients with traumatic and aortic disease. J Surg Res 184:613–8

    Article  PubMed  Google Scholar 

  17. Farber MA, Giglia JS, Starnes BW, Stevens SL, Holleman J, Chaer R, Matsumura JS (2013) Evaluation of the redesigned conformable GORE TAG thoracic endoprosthesis for traumatic aortic transection. J Vasc Surg 58:651–8

    Article  PubMed  Google Scholar 

  18. Hsu HL, Chen CK, Chen PL, Chen IM, Hsu CP, Chen CW, Shih CC (2014) The impact of bird-beak configuration on aortic remodeling of distal arch pathology after thoracic endovascular aortic repair with the Zenith Pro-Form TX2 thoracic endograft. J Vasc Surg 59:80–8

    Article  PubMed  Google Scholar 

  19. Geisbüsch P, Kotelis D, Hyhlik-Dürr A, Hakimi M, Attigah N, Böckler D (2010) Endografting in the aortic arch—does the proximal landing zone influence outcome? Eur J Vasc Endovasc Surg 39:693–699

    Article  PubMed  Google Scholar 

  20. Kotelis D, Lopez-Benitez R, von Tengg-Kobligk H, Geisbüsch P, Böckler D (2008) Endovascular repair of stent graft collapse by stent-protected angioplasty using a femoral-brachial guidewire. J Vasc Surg 48:1609–12

    Article  PubMed  Google Scholar 

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

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Informed consent was obtained from all individual participants included in the study.

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Correspondence to Drosos Kotelis.

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Kotelis, D., Brenke, C., Wörz, S. et al. Aortic morphometry at endograft position as assessed by 3D image analysis affects risk of type I endoleak formation after TEVAR. Langenbecks Arch Surg 400, 523–529 (2015).

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