Type II Endoleak Embolization Choice of Materials: EVOH, Glue, Thrombin & Coils. Michael S. Rosenberg, MD Assistant Professor of Radiology
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1 Type II Endoleak Embolization Choice of Materials: EVOH, Glue, Thrombin & Coils Michael S. Rosenberg, MD Assistant Professor of Radiology
2 Michael Rosenberg, M. D. No relevant financial relationship reported Off-label discussion
3 Endoleak White GH, et al 1996 Endoleak--a proposed new terminology to describe incomplete aneurysm exclusion by an endoluminal graft. J Endovasc Surg Feb;3(1):124-5
4 Evidence 2 Decades Experience Controversy
5 Type I & III Endoleak High pressure High risk Urgent management often required
6 Significance of Type II Endoleaks Low pressure Low risk Expectant management
7 Significance of Type II Endoleaks Up to 50% incidence immediately post repair 75-90% resolve at 1 month No difference in: -Patient survival -Rupture rate -Surgical conversion -Graft migration Monitor and treat for progressive aneurysm sac enlargement > 5mm or if symptomatic Technical & clinical success > 70 % experienced operators 1 1 Chung R. Cardiovasc Intervent Radiol. 2015;38:
8 Treatment Type II Endoleaks
9 Treatment Type II Endoleaks Embolization Approach Transarterial Translumbar Rarely Transabdominal Transcaval Transarterial perigraft catheterization Material Coils Liquid embolics Cyanoacrylate glue Onyx Ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide (DMSO) Thrombin
10 Coils Choice of Materials pushable or detachable Good control with low risk of non-target embolization Feeding & draining branches, nidus Risk of incomplete embolization Multiple branches Early recurrence if only treat the branch and not the nidus. T2EL AVM
11 Pre-EVAR IMA Embolization
12 108 patients IMA embolization before EVAR compared to 158 patients no pre-evar IMA embolization Type II endoleaks % vs 49.4% (p=0.015) Secondary interventions - 0.9% vs 7.6% (p=0.013) AAA sac volume enlargement at 24 months 26% vs 47% (p=0.03) J Vasc Interv Radiol 2013; 24:49-55
13 Choice of Materials Thrombin Relatively high endoleak recurrence Up to 50% in small case series 1 Dual antiplatelet therapy Risk of non-target embolization Not visible - U/S guidance 1 Uthoff H, et al. J Vasc Surg 2012 Oct;56(4);965-72
14 Choice of Materials n-butyl-2-cyanoacrylate Glue (n-bca) 1:3 glue:ethiodol Test inject contrast and reproduce same volume & rate with glue One chance! Experienced operator Complete embolization nidus and branches Inflammatory reaction durability Risk of non-target embolization Adhesive can glue in catheter
15 Type II Endoleak Translumbar Glue Embolization
16 Type II Endoleak Translumbar Glue Embolization
17 Choice of Materials Ethylene Vinyl Alcohol Copolymer - Onyx Onyx 18 or 34 dissolved in dimethyl sulfoxide (DMSO) Non-adhesive / cohesive Slowly propagates from catheter tip
18 Onyx vs Glue Pros Easier to control Safer Risk nontarget embolization Non-adhesive cannot glue in catheter Cons Time consuming Difficult to propagate to branches Expensive DMSO Pain, vessel irritant
19 Type II Endoleak Transarterial Onyx Embolization
20 Type II Endoleak Transarterial Onyx Embolization
21 Type II Endoleak Transarterial Onyx Embolization Post Onyx Post Onyx
22 Single center retrospective review 18 patients Onyx ± coil/glue/vascular plug 66.7% overall clinical success 72.5 ( 32.8) months Unchanged or decreased aneurysm sac size 44.4% required secondary intervention
23 Treatment Type II Endoleaks Case 73 y/o male Endurant stent graft 2/3/2012 2/2013 coiling of IMA for type II leak 2/13/2014 CTA two persistent areas of type II endoleak with increasing aneurysm sac size
24 Courtesy J. Golzarian MD
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27 3/19/2014 Coiling and MVP plug embolization via left iliolumbar approach
28 Courtesy J. Golzarian MD
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34 5/4/2015 CTA persistent additional type II leak with increase in AAA diameter from 6.5 cm to 6.7 cm and volume from 208 ml to 220 ml
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36 6/3/2015 Angiography Translumbar n-bca glue embolization
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39 Translumbar Access Fluoro and Cone Beam CT
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44 Conclusions Treatment of type II endoleaks remains controversial Treatment indicated for expanding or symptomatic aneurysms Onyx &/or glue ± coils promising Choice of embolic material depends upon experience and comfort of the operator Treat nidus and the feeding vessels
Approaches to type II Endoleaks: Transcaval, transarterial, translumbar. Saher Sabri,MD University of Virginia
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