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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
University of Virginia Health System, Department of Radiology & Medical Imaging
• 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
University of Virginia Health System, Department of Radiology & Medical Imaging
• 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)
University of Virginia Health System, Department of Radiology & Medical Imaging
• 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
University of Virginia Health System, Department of Radiology & Medical Imaging
Think of complex endoleaks
like an AVM with a “Nidus”
AAA
AVM
University of Virginia Health System, Department of Radiology & Medical Imaging
Access
• Direct sac puncture
• Trans-arterial
• Trans-Caval
University of Virginia Health System, Department of Radiology & Medical Imaging
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)
University of Virginia Health System, Department of Radiology & Medical Imaging
Direct Sac Access Angiogram – Onyx Embolization
University of Virginia Health System, Department of Radiology & Medical Imaging
Pre Post
University of Virginia Health System, Department of Radiology & Medical Imaging
Pre-Onyx Post-Onyx
University of Virginia Health System, Department of Radiology & Medical Imaging
CT Angiogram – Type II Endoleak
Aneurysm sac measures 5.3 cm
University of Virginia Health System, Department of Radiology & Medical Imaging
Complex Type II Endoleak
( Ant and Post components)
University of Virginia Health System, Department of Radiology & Medical Imaging
Direct Sac Puncture – Type II Endoleak
Conebeam CT
Sac Puncture
University of Virginia Health System, Department of Radiology & Medical Imaging
AP Lat
Sac angiogram
shows IMA
outflow
IMA IMA
University of Virginia Health System, Department of Radiology & Medical Imaging
IMA access via
direct sac puncture
IMA
embo
with
coils
Onyx
embo
Nidus
University of Virginia Health System, Department of Radiology & Medical Imaging
Endoleak Treatment – F/U CTA
Contrast CT Pre-Onyx Non-contrast CT Post Onyx
University of Virginia Health System, Department of Radiology & Medical Imaging
Complications
• Psoas hematoma
• Transient Lumbar nerve paresis
• Retroperitoneal Onyx/glue leak
• Complications are usually minor
without clinical sequelae
University of Virginia Health System, Department of Radiology & Medical Imaging
Transarterial access
• SMA-IMA pathway
• Iliolumbar pathway
University of Virginia Health System, Department of Radiology & Medical Imaging
Transarterial Embolization –SMA/IMA
University of Virginia Health System, Department of Radiology & Medical Imaging
Transarterial Embolization-Lumbar outflow
University of Virginia Health System, Department of Radiology & Medical Imaging
Transarterial Embolization
University of Virginia Health System, Department of Radiology & Medical Imaging
Transarterial Embolization
University of Virginia Health System, Department of Radiology & Medical Imaging
Transarterial Embolization
University of Virginia Health System, Department of Radiology & Medical Imaging
Type II Endoleak• 78 year old s/p EVAR 6 months ago
• Since 1 month scan Type II endoleak with 5 mm aneurysm
growth
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
IMA Not
contributing
University of Virginia Health System, Department of Radiology & Medical Imaging
Aortic sac filling
Trans-iliolumbar access
Internal iliac angiogram
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
Prior lumbar embo
Transcaval access
University of Virginia Health System, Department of Radiology & Medical Imaging
Transcaval access
Trans-septal
needle
0.018 wire
University of Virginia Health System, Department of Radiology & Medical Imaging
Microcatheter
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
University of Virginia Health System, Department of Radiology & Medical Imaging
Type II Leak Resolved—No AAA
Growth at 6 months
University of Virginia Health System, Department of Radiology & Medical Imaging
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.
University of Virginia Health System, Department of Radiology & Medical Imaging
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
University of Virginia Health System, Department of Radiology & Medical Imaging
Peri-iliac-graft access
University of Virginia Health System, Department of Radiology & Medical Imaging
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
University of Virginia Health System, Department of Radiology & Medical Imaging
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
University of Virginia Health System, Department of Radiology & Medical Imaging
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
University of Virginia Health System, Department of Radiology & Medical Imaging
Q # 2 Trans-caval access for endoleak
embolization is associated with a higher
bleeding risk than percutaneous direct sac
puncture
• A. True
• B. False
University of Virginia Health System, Department of Radiology & Medical Imaging
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)