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Thursday, July 26, 2018

Transabdominal Direct Sac Puncture Embolization of Type II Endoleaks after Endovascular Abdominal Aortic Aneurysm Repair


Researchers from the University of Toronto are reporting the experience with type II endoleak repair via a transabdominal direct sac puncture. This is a retrospective review of 30 patients. Inclusion criteria included the presence of safe, unobstructed access from the anterior abdominal wall to the perfused part of the sac, without needing to traverse organs or major intervening arterial structures. Patients without unobstructed access, and patients with isolated IMA endoleak without lumbar artery contribution, were excluded from the study. The authors used US-guidance to access the sac to avoid bowel and adjacent organs/vessels. An 18-gauge trocar needle was used with placement of a hemostatic valve at the hub following sac access. A 2.4 F microcatheter was then placed through the needle and used to select feeding vessels, if able. In treated patients, embolization materials included cyanoacrylate glue (45.5%), glue/coils (36.4%), and Onyx with or without glue/coils (18.1%). Technical success was defined as complete endoleak embolization on fluoro. The primary outcome was freedom from sac growth defined as ≤ 5% sac growth on CT or ≤ 5mm change in sac diameter on US. The team reported a technical success rate in 97% of patients with mean follow-up of 15.5 months. Freedom from sac growth was seen in 85.2% of patients. Complications were seen in only 3 of 33 procedures and included 1 nontarget embolization with transient neuropraxia and 2 self-limiting rectus sheath hematomas. The authors concluded that percutaneous transabdominal embolization is a safe and efficacious treatment for type II endoleak, with a short procedure time.

Fig 1
Ultrasound (a) with Doppler demonstrates an area of endoflow (arrow) in the posterior right of the aneurysm sac, which was (b) subsequently targeted, and a needle was advanced into it under ultrasound guidance, with the needle tip (arrow) positioned within the posterior aspect.

Fig 2
Fluoroscopic image demonstrates (a) a patent IMA (arrow), which was (b) subsequently coil embolized at sac origin to protect the IMA from nontarget embolization (arrow). In addition, a feeding right lumbar artery (arrowhead) and the aneurysm sac (asterisk) were embolized.


This manuscript is noteworthy as it effectively shows that transabdominal direct sac puncture can be a safe and effective method for treatment of type II endoleaks. For anyone that is fortunate (or unfortunate) enough to treat type II endoleaks, they will understand well the challenge of treating endoleaks that lack a defined IMA source. Transarterial access into the culprit lumbar vessel(s) is always challenging and often impossible. Further, it is often difficult to prospectively identify patients that will be adequate candidates for a transarterial approach. The present study provides a convincing argument for incorporating transabdominal direct sac access into the treatment algorithm. This approach may not be suitable in all patients secondary to body habitus and need for continuous compression for bowel displacement at time of ultrasound-guided access. However, with a noteworthy 85% freedom from sac growth, it is worth considering in patients with a lumbar source of type II endoleak.

Click here for abstract

Zener R, Oreopoulos G, Beecroft R, Rajan DK, Jaskolka J, Tan KT. Transabdominal direct sac puncture embolization of type II endoleaks after endovascular abdominal aortic aneurysm repair. J Vasc Interv Radiol. 2018; 29: 1167-1173.

Post Author:
Luke R. Wilkins, MD
Assistant Professor
Department of Radiology and Medical Imaging
Section of Vascular and Interventional Radiology
University of Virginia

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