Percutaneous Transluminal Embolization of Type II Endoleak
This section provides a comprehensive procedural report for percutaneous transluminal embolization of Type II endoleak procedure with up-to-date explanatory notes, synopsis of the indications and contraindications, and potential complications in an organi
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Eric T. Aaltonen
Abbreviations
EVAR IMA CT US
Endovascular aneurysm repair Inferior mesenteric artery Computed tomography Ultrasound
INTRODUCTION Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms has become a widely accepted alternative to open repair with similar survival and rupture outcomes. There are five subtypes of endoleak following EVAR; type II endoleak is the most common (40 %) and involves perigraft blood flow via an artery arising from the aneurysm sac [1]. There are two subtypes of type II endoleaks, single vessel inflow and outflow is characterized as IIA and multiple inflow/outflow vessels are characterized as IIB.
E.T. Aaltonen (&) Department of Radiology, New York University Langone Medical Center, 660 1st Avenue, New York, NY 10016, USA e-mail: [email protected]
The annual incidence of type II endoleaks following endovascular aneurysm repair is approximately 5–8 % [2, 3]. The presence of a type II endoleak on imaging is associated with a very low risk of rupture if there is no accompanying increase in aneurysm sac diameter and these endoleaks often resolve spontaneously. However, growth of the aneurysm sac associated with a type II endoleak is concerning for impending rupture. A 5 mm interval increase in maximum diameter of the sac over a 6-month period is a widely accepted treatment threshold [4]. Treatment of a type II endoleak requires cessation of the inflow/outflow of perigraft blood by embolization either via a percutaneous transluminal or transarterial approach. These two techniques have been shown to have similar success and complication outcomes [5]. Regardless of technique, the sac must be embolized centrally much like the nidus of an arteriovenous malformation to achieve success. Percutaneous puncture of the aneurysm sac can be achieved by a translumbar or transabdominal approach and is typically performed with computed tomography (CT), ultrasound (US), or fluoroscopic guidance.
© Springer International Publishing Switzerland 2016 B. Taslakian et al. (eds.), Procedural Dictations in Image-Guided Intervention, DOI 10.1007/978-3-319-40845-3_77
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COMMON INDICATIONS [4, 6] Absolute Indications: • 5 mm or greater increase in maximum aneurysm sac diameter over a 6-month period during EVAR surveillance Relative Indications: • Less than 5 mm increase in maximum aneurysm sac diameter over a 6-month surveillance period • 5 mm or greater increase in maximum aneurysm sac diameter over a surveillance period longer than 6 months
COMMON CONTRAINDICATIONS • Unsafe window for percutaneous access to aneurysm sac • Severe coagulopathy that cannot be corrected (relative contraindication)
POSSIBLE COMPLICATIONS [4, 7] • • • •
Endograft perforation Endograft infection Hemorrhage/hematoma Nontarget embolization (ischemia secondary to embolic material in distal IMA branches) • Injury to adjacent structures (overlying bowel, kidneys, inferior vena cava, other vasculature)
PREPROCEDURAL ASSESSMENT AND PLANNING [8–10] • History, indications, and physical examination (
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