Laparoscopic Clipping of the Inferior Mesenteric Artery for the Treatment of Type II Endoleak Using Intra-operative...

Type II endoleaks (T2ELs) are a common finding after endovascular aortic repair (EVAR), often caused by retrograde flow from the inferior mesenteric artery (IMA). Although transarterial embolisation is standard, laparoscopic IMA ligation may provide a definitive alternative in selected cases. Indocyanine green fluorescence angiography (ICG-FA) adds real time vascular visualisation, helping the identification and confirmation of successful ligation. This report illustrates the potential benefit of Indocyanine green guided laparoscopic IMA clipping for managing T2ELs.

The case of a 69 year old man with an abdominal aortic aneurysm who underwent emergency EVAR for a ruptured left iliac artery aneurysm is presented. At two year follow up, computed tomography angiography revealed a persistent T2EL originating from the IMA, resulting in abdominal aortic aneurysm growth. Given the aneurysm's progression, laparoscopic IMA clipping using ICG-FA was performed. The IMA was identified, and ICG-FA was used to confirm its precise location before applying ligation clips to occlude the vessel. Successful exclusion was further confirmed with repeated ICG-FA. Post-operative recovery was uneventful, and no endoleaks were detected on follow up imaging (computed tomography angiography).

ICG-FA laparoscopic clipping of the IMA may offer a safe and effective treatment option in selected cases for persistent T2ELs after EVAR. Compared with endovascular options, it allows direct exclusion of the inflow vessel with real time visual confirmation. ICG-FA can provide real time functional imaging of vascular perfusion, enabling intra-operative identification of the IMA and objective confirmation of successful vessel occlusion. Its integration is practical, widely accessible, and may increase the safety and confidence of laparoscopic IMA ligation in selected patients.