approaches to type ii endoleaks: transcaval, … to type ii endoleaks: transcaval, transarterial,...

Approaches to type II

Endoleaks: Transcaval,

transarterial, translumbar

Saher Sabri ,MD

University of Virginia

Saher Sabri, M.D.

• Speakers Bureau: W.L.Gore & Associates, Abbott

University of Virginia Health System, Department of Radiology & Medical Imaging

• Type II Endoleaks

– 10-25% incidence

– Natural history unclear

• management of Type II

endoleaks is controversial

• >60% spontaneously

resolve

• Rupture is rare

Type 2 Endoleaks after EVAR


• Persistent type II endoleaks are

associated with

• Increased risk of sac growth ( OR 26)

• Significant predictor of aneurysm

rupture

• No increase in aneurysm related

mortality

Jones et al JVS 2007 ;46:1-8


• Type II endoleak with stable diameter

does not demonstrate higher rate of

rupture compared with stable aneurysms

without endoleak

• Van Marrewijk et al ( JVS 2002;35 :46-473)


• Type II endoleaks

– Decrease sac size – No therapy

– Increase sac size – Treat

– Stable sac size – when to treat? • Persistent > 6 months ?

• Predictors of persistent endoleaks

– Numerous collaterals (>3 vessels)

– Large central nidus (>15 mm)

– High flows (velocities >100cm/s)

– Chronic anticoagulation

Endoleak Management


Think of complex endoleaks

like an AVM with a “Nidus”

AAA

AVM


Access

• Direct sac puncture

• Trans-arterial

• Trans-Caval


Direct sac puncture

• Fluoro guided

• Cone beam CT or Fusion software

• 22 g access needle

• Transition to 4-6 fr

• Embolize through a microcatheter ( as

needed)


Direct Sac Access Angiogram – Onyx Embolization


Pre Post


Pre-Onyx Post-Onyx


CT Angiogram – Type II Endoleak

Aneurysm sac measures 5.3 cm


Complex Type II Endoleak

( Ant and Post components)


Direct Sac Puncture – Type II Endoleak

Conebeam CT

Sac Puncture


AP Lat

Sac angiogram

shows IMA

outflow

IMA IMA


IMA access via

direct sac puncture

IMA

embo

with

coils

Onyx

embo

Nidus


Endoleak Treatment – F/U CTA

Contrast CT Pre-Onyx Non-contrast CT Post Onyx


Complications

• Psoas hematoma

• Transient Lumbar nerve paresis

• Retroperitoneal Onyx/glue leak

• Complications are usually minor

without clinical sequelae


Transarterial access

• SMA-IMA pathway

• Iliolumbar pathway


Transarterial Embolization –SMA/IMA


Transarterial Embolization-Lumbar outflow


Transarterial Embolization


Type II Endoleak• 78 year old s/p EVAR 6 months ago

• Since 1 month scan Type II endoleak with 5 mm aneurysm

growth


IMA Not

contributing


Aortic sac filling

Trans-iliolumbar access

Internal iliac angiogram


Prior lumbar embo

Transcaval access


Transcaval access

Trans-septal

needle

0.018 wire


Microcatheter


Type II Leak Resolved—No AAA

Growth at 6 months


Transcaval Endoleak Embolization• 29 embolizations in 26 patients for type II endoleaks with

aneurysm growth

• Mean of 4.2 ± 4 years after EVAR

• 46% had prior procedures (5 translumbar, 3 transarterial, 3 transcaval, 1 aortic cuff, and 1 iliac limb extension)

• 2 had no flow identified in the aneurysm sac (1 had a hygromarather than arterial flow)

• 83% success in getting transcaval access to aorta

• Mean fluoroscopy time was 27 ± 13 minutes with 29 ± 21 mL of contrast – median of 10 coils per case

– thrombin injection (17%)

• No procedural adverse events

• One-year freedom from reintervention 95%

Giles KA, et al. Results of transcaval embolization for sac expansion

from type II endoleaks after endovascular aneurysm repair. J Vasc

Surg. 2015 May;61(5):1129-36.


Suggested algorithm for Type II

• IMA patent : Transarterial SMA-IMA

access

• IMA occluded : Transarterial iliolumbar

access Or Direct sac puncture

• Personal preference: start with iliolumbar

access and reserve direct sac for failed

iliolumbar access ( diminutive iliolumbar

arterial pathway) or residual endoleak

• Transcaval for right sided endoleaks


Peri-iliac-graft access


Peri-iliac-graft access

Wedge a 5 fr catheter between the iliac wall and

the graft and access the sac with a microcatheter

even in the absence of type 1 b endoleak


Q #1 Which of the following

about type II endoleak is true

• A. Persistent endoleak with no sac diameter

enlargement leads to higher incidence of rupture

• B. Type II endoleaks are associated with higher

aneurysm related mortality

• C. Type II endoleaks persistent beyond 6 months are

predictors of increase in sac diameter

• D. Type II endoleak post TEVAR have similar incidence

to type II endoleaks post EVAR


Q #1 Which of the following

about type II endoleak is true

• A. Persistent endoleak with no sac diameter

enlargement leads to higher incidence of rupture

• B. Type II endoleaks are associated with higher

aneurysm related mortality

• C. Type II endoleaks persistent beyond 6 months are

predictors of increase in sac diameter ( correct answer)

• D. Type II endoleak post TEVAR have similar incidence

to type II endoleaks post EVAR


Q # 2 Trans-caval access for endoleak

embolization is associated with a higher

bleeding risk than percutaneous direct sac

puncture

• A. True

• B. False


Q # 2 Trans-caval access for endoleak

embolization is associated with a higher

bleeding risk than percutaneous direct sac

puncture

• A. True

• B. False ( correct answer)

approaches to type ii endoleaks: transcaval, … to type ii endoleaks: transcaval, transarterial,...

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