Ischaemic Sequelae Following Glue Embolization of Type 2 Endoleak Involving Multiple Lumbar Arteries
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LETTER TO THE EDITOR
ARTERIAL INTERVENTIONS
Ischaemic Sequelae Following Glue Embolization of Type 2 Endoleak Involving Multiple Lumbar Arteries Joo-Young Chun1
•
Robert Morgan1
Received: 14 April 2020 / Accepted: 26 June 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
Dear Editor, We wish to report an unusual but important complication of embolization of a lumbar type 2 endoleak using N-butyl cyanoacrylate (NBCA). A 74-year-old man underwent bifurcated EVAR for AAA in 2017. A surveillance duplex ultrasound scan two and a half years later showed that the sac size had increased by 10 mm. A CTA confirmed a large type 2 endoleak involving L4 and L5 lumbar arteries. The patient underwent transarterial embolization of the type 2 endoleak under local anaesthesia via left femoral access. The left iliolumbar artery was chosen as the entry vessel into the endoleak sac, which was superselectively catheterized with a microcatheter. The microcatheter was advanced into the left L5 lumbar artery and into the endoleak cavity (nidus). Angiography performed from within the endoleak nidus showed opacification of a large endoleak cavity as well as both L4 lumbar arteries and the right L5 lumbar artery (Fig. 1). Embolization of the endoleak was performed using Glubran 2 (GEM, Viareggio, Italy), which was mixed with lipiodol in a 1:4 ratio. During glue injection, the glue cast filled the endoleak cavity first and then disintegrated intermittently to opacify the exiting lumbar arteries, one at a time. Completion images showed the glue cast within the aneurysm sac and bilateral L4 and L5 lumbar arteries. Unfortunately, glue was also seen within the distal branches of the L4 lumbar arteries and to a lesser extent the
& Joo-Young Chun [email protected] 1
Department of Radiology, St George’s Hospital, London, UK
right L5 lumbar artery (Fig. 2). Completion angiography showed no further endoleak. The patient developed lower back pain and bilateral thigh pain several hours following the procedure, which required opioid analgesia. He was discharged the following day after a duplex ultrasound confirmed no evidence of residual endoleak. His symptoms persisted for several weeks but gradually diminished over time, and resolved completely in 2 months. An MRI of the lumbar spine showed abnormal marrow signal in the L4 vertebral body, suggestive of medullary infarction (Fig. 3). Non-target embolization resulting in neurological symptoms is uncommon following type 2 endoleak embolization of lumbar arteries. Only two reports allude to similar complications. The first report was published by Kajiwara et al. [1] who described two cases of back pain, one of whom developed transient lower limb muscle weakness. In both cases, a 1:10 histoacryl/lipiodol mixture was used as the sole embolic agent. The second report was published by Zener et al. [2] who described neuropraxia and neuromuscular injury in one patient. Again, histoacryl was used as th
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