Persistent Type II endoleaks after endovascular aneurysm repair (EVAR) often cause significant aneurysm sac expansion. While endovascular embolization remains the standard first-line therapy, it occasionally fails to stop the backflow entirely. Therefore, Laparoscopic IMA clipping serves as a highly effective, minimally invasive alternative for these refractory cases. For example, an 87-year-old male recently presented with progressive sac enlargement and successfully underwent this specialized surgical intervention after initial management attempts failed.

Technique and Success of Laparoscopic IMA Clipping

During the procedure, the surgeon utilizes a transperitoneal route to access the inferior mesenteric artery directly. By placing titanium clips on the vessel, they immediately stop the retrograde blood flow into the aneurysm sac. Furthermore, intraoperative ultrasound allows for real-time physiological confirmation of the endoleak cessation. Studies specifically report that Laparoscopic IMA clipping achieves a technical success rate between 90% and 100% in specialized centers. This high rate of success makes it a reliable fallback when endovascular access is restricted by anatomy.

Advantages of the Surgical Strategy

This surgical strategy is especially useful for patients with complex anatomy that complicates standard endovascular access. Moreover, the laparoscopic technique avoids the repetitive use of contrast media and ionizing radiation often required in multiple embolization attempts. Consequently, the procedure offers a safer profile for elderly patients with renal concerns. In contrast to open surgery, this approach significantly reduces recovery time while definitively preventing the risk of aneurysm rupture. Clinical outcomes demonstrate that most patients experience sac regression or stabilization shortly after the procedure.

Frequently Asked Questions

When should clinicians consider laparoscopic IMA clipping?

It is indicated for persistent Type II endoleaks associated with aneurysm sac expansion of more than 5 mm where endovascular embolization has failed or is technically unfeasible.

How is flow cessation verified during the procedure?

Flow cessation is typically verified using intraoperative laparoscopic ultrasound or indocyanine green (ICG) angiography, providing immediate confirmation that the leak has stopped.

Is this procedure safe for elderly patients?

Yes, as a minimally invasive technique, it carries lower operative risks compared to open surgical conversion and avoids the contrast and radiation exposure associated with repeated endovascular interventions.

Disclaimer: This content is for informational and educational purposes only and does not constitute medical advice. Always seek the advice of a qualified healthcare provider regarding any medical condition or treatment. Refer to the latest local and national guidelines for clinical practice.

References

1. Hassan MB et al. Total Laparoscopic Inferior Mesenteric Artery Clipping for Persistent Type II Endoleak Following EVAR: A Case Report and Review of Surgical Strategy. Vasc Endovascular Surg. 2026 May 07. doi: 10.1177/15385744261441978. PMID: 42095299.
2. Spanos K, et al. Systematic review of laparoscopic ligation of inferior mesenteric artery for the treatment of type II endoleak after endovascular aortic aneurysm repair. J Vasc Surg. 2017.
3. Kouvelos GN, et al. A Systematic Review and Meta-Analysis of Laparoscopic Ligation of the Inferior Mesenteric Artery for the Treatment of Type II Endoleaks. J Clin Med. 2022.