030 - Dealer’s Choice: Embolization Techniques for Type II Endoleak
Mustafa Al-Roubaie, MD – Attending Physician, Department of Vascular and Interventional Radiology, Northwell Health
Purpose: To discuss indications for treatment of type II endoleak and describe five treatment approaches via embolization which often depend on operator preference but can be influenced by anatomical considerations.
Material and Methods: This presentation collates information from current literature on various embolization techniques for type II endoleak treatment, including their drawbacks.
Results: Endoleak occurs following EVAR when perfusion of the aneurysm sac persists despite endograft deployment. The most common is type II endoleak, occurring in up to 30% of patients when feeding vessels excluded by the graft pressurize the sac. While some resolve spontaneously, treatment is indicated if the endoleak results in persistent sac expansion (>5mm increase in diameter and/or >5% increase in volume). The transarterial approach uses transfemoral arterial access to embolize the aneurysm nidus and feeding vessels via retrograde transcollateral catheterization. Drawbacks include difficulty with catheterizing tortuous vessels, and subsequent conversion to the translumbar approach. The translumbar approach is performed on the prone patient where the sac is accessed percutaneously at the level of the endoleak using fluoroscopic guidance. Drawbacks include a tenuous passage near the IVC during right-sided approaches, and difficulties embolizing afferent and efferent vessels. The transabdominal approach is performed on the supine patient, resulting in direct anterior sac access via ultrasound guidance. Drawbacks include bowel injury and passage difficulties in obese patients. The transcaval approach, useful for right sided endoleaks and those lying close to the IVC, uses IJ or transfemoral venous access to pass an IVC needle into the aneurysm sac. Drawbacks include pulmonary embolism from non-target embolization, retroperitoneal bleeding, and aortocaval fistula. Perigraft arterial sac embolization (PASE) involves sac access via a transfemoral arterial approach to enter the potential space between the endograft’s distal aspect and common iliac arterial wall. Drawbacks include nontarget embolization of femoral and visceral vessels, inability to access the excluded segment, and subintimal catheterization.
Conclusions: The five embolization techniques to repair type II endoleak require complex catheterization skills but vary in their employment due to operator preferences and anatomical considerations. These techniques can be used alone or in combination.