Approaches to type II Endoleaks: Transcaval, transarterial, translumbar. Saher Sabri,MD University of Virginia

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1 Approaches to type II Endoleaks: Transcaval, transarterial, translumbar Saher Sabri,MD University of Virginia

2 Saher Sabri, M.D. Speakers Bureau: W.L.Gore & Associates, Abbott

3 Type 2 Endoleaks after EVAR Type II Endoleaks 10-25% incidence Natural history unclear management of Type II endoleaks is controversial >60% spontaneously resolve Rupture is rare

4 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

5 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)

6 Endoleak Management 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

7 Think of complex endoleaks like an AVM with a Nidus AVM AAA

8 Access Direct sac puncture Trans-arterial Trans-Caval

9 Fluoro guided Direct sac puncture Cone beam CT or Fusion software 22 g access needle Transition to 4-6 fr Embolize through a microcatheter ( as needed)

10 Direct Sac Access Angiogram Onyx Embolization

11 Pre Post

12 Pre-Onyx Post-Onyx

13 CT Angiogram Type II Endoleak Aneurysm sac measures 5.3 cm

14 Complex Type II Endoleak ( Ant and Post components)

15 Direct Sac Puncture Type II Endoleak Conebeam CT Sac Puncture

16 IMA Sac angiogram shows IMA outflow IMA AP Lat

17 Onyx embo IMA access via direct sac puncture IMA embo with coils Nidus

18 Endoleak Treatment F/U CTA Contrast CT Pre-Onyx Non-contrast CT Post Onyx

19 Complications Psoas hematoma Transient Lumbar nerve paresis Retroperitoneal Onyx/glue leak Complications are usually minor without clinical sequelae

20 Transarterial access SMA-IMA pathway Iliolumbar pathway

21 Transarterial Embolization SMA/IMA

22 Transarterial Embolization-Lumbar outflow

23 Transarterial Embolization

24 Transarterial Embolization

25 Transarterial Embolization

26 Type II Endoleak 78 year old s/p EVAR 6 months ago Since 1 month scan Type II endoleak with 5 mm aneurysm growth

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29 IMA Not contributing

30 Trans-iliolumbar access Internal iliac angiogram Aortic sac filling

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38 Transcaval access Prior lumbar embo

39 Transcaval access Trans-septal needle wire

40 Microcatheter

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44 Type II Leak Resolved No AAA Growth at 6 months

45 Giles KA, et al. Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair. J Vasc Surg May;61(5): 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 hygroma rather 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%

46 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

47 Peri-iliac-graft access

48 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

49 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

50 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

51 Q # 2 Trans-caval access for endoleak embolization is associated with a higher bleeding risk than percutaneous direct sac puncture A. True B. False

52 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)