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Abstract No. 352: Evolving techniques for type II endoleak management after endovascular aneurysm repair (EVAR)
JVIR 䡲 Poster Sessions
S145
vascular management is suitable for patients with aneurysm rupture and hemodynamic instability. It is the desirable method of treatment in patients with multiple co-morbidities, especially malignancy. It is also associated with a decreased length of hospital stay in the elective setting. Also, failure of primary treatment can be managed with repeat percutaneous procedures. It is the ideal method of management in surgically “hard-to- access,” intra-pancreatic and peri-pancreatic territories. The majority of the pseudo-aneurysms can be successfully treated with endovascular repair. In congenitally abnormal and fragile arteries, where surgical dehiscence is likely, endovascular treatment may present a less traumatic option.
Educational Exhibit
Abstract No. 352
Evolving techniques for type II endoleak management after endovascular aneurysm repair (EVAR) J.H. Brannen, R. Oklu, S. Ganguli, G.M. Salazar, S.P. Kalva, A. Waltman, C.J. Kwolek, S. Wicky, G. Walker; Cardiovascular Imaging and Intervention, Massachusetts General Hospital, Boston, MA
Abstract No. 353
Percutaneous ultrasound guided embolization of postcatheterization femoral pseudoaneurysm using pushable fibered coil S.E. Hegab; Radiodiagnosis and Interventional Radiology, Alexandria University, Alexandria, Egypt Learning Objectives: The diagnosis of femoral pseudoaneurysm is usually straight forward and is made on the combination of physical examination and color duplex ultrasound findings.Many techniques were used for occlusion of the pseudoaneurysm, including US guided compression, thrombin injection and surgical reconstruction. Background: This study included six patients, five adult patients and one child three years old, had femoral pseudoaneurysm postcatheterization. Embolization was carried out after failure of US guided compression. The pseudoaneurysm diameter ranged from 28 to 54 mm diameter. The size of coil was one to two mm more than the diameter of the neck of the pseuodoaneurysm. Puncture of the pseudoaneurysm, coil embolization and confirming the occlusion of the peudoaneurysms were achieved using only Ultrasonography, without fluoroscopy or contrast examination. The Teflon coated puncture needle used was 16 –14 G and 15 cm length. Local anesthesia was used in the adult patients and general anaethesia for the young child patient. Clinical Findings/Procedure Details: Successful complete embolization was achieved in the six pseudoaneurysms. Immediate thrombosis of the pseudoneurysm was seen after delivery of the coil, using one coil in four lesions and two coils in the remaining two pseudoaneurysms. Bed rest for one hour after the embolization then the patient was discharged. Follow up from 3– 6 months showed complete embolization of the pseudoaneurysms, and significant regression in the size was noted in three patients. No complications were encountered inspite the patients were on anticoagulant and/or antiplatlet treatment. Conclusion and/or Teaching Points: We conclude that percutaneous US guided coil embolization of the femoral pseudoaneurysm is a safe and simple outpatient procedure that will avoid surgical reconstruction in many patients.
Educational Exhibit
Abstract No. 354
Diagnosis and management of abdominal aortic endograft infections A.A. Naiem; Radiology, University of Maryland Medical Center, Baltimore, MD Learning Objectives: This exhibit reviews the risk factors, clinical clues, and manifestations of abdominal aortic endograft infection, as well as associated cross-sectional, angiographic, and nuclear medicine imaging. Treatment options, including conservative medical, surgical and percutaneous intervention will be discussed in detail. Background: Abdominal aortic endograft infection has a reported incidence of 0.43% to 2%. However, the high mortality after diagnosis ranging from 18% to 70% demands a greater understanding of the signs and symptoms of endograft infection as well as the associated risks and its prevention. Given the infrequent occurrence of endograft infection, the diagnosis and management continues to evolve. Clinical Findings/Procedure Details: The exhibit draws upon our experience with endograft infection from an overall
Poster Sessions
Learning Objectives: Review the current management of type II endoleaks after EVAR, including intervention options and their effectiveness. Background: Post-EVAR type II endoleaks occur in up to 25% of patients due to continued aneurysm perfusion via patent branch vessels normally arising from the aorta (e.g. lumbar, inferior mesenteric arteries). These endoleaks are usually seen on surveillance imaging and have variable clinical significance. Although the majority resolve spontaneously, there is a subset in which continued perfusion causes an increase in both aneurysm sac size and rupture risk. Endoleak management continues to evolve. Whereas previously many investigators aggressively treated all type II endoleaks, a more common strategy is now one of surveillance, with intervention reserved for sac growth. Clinical Findings/Procedure Details: Preoperative embolization of major branch vessels that may potentially cause a type II endoleak is sometimes performed, but intervention is typically reserved for post-EVAR type II endoleaks causing an increase in the residual aneurysm sac volume. There are two general strategies for type II endoleak management: embolization of branch vessels perfusing the aneurysm sac and direct sac embolization. In the former, all vessels perfusing the aneurysm sac are accessed and embolized via a standard transarterial approach, with coils typically used as the embolic agent. A more common treatment is direct sac embolization via either translumbar sac puncture or a transarterial approach in which sac access is obtained by selective catherization of the feeding branch vessel(s). In either instance, the goal is eliminating the “nidus” that remains perfused (i.e. aneurysm sac). Commonly used embolic agents include coils, vascular plugs, thrombin, N-butyl cyanoacrylate and Onyx. The latter has recently seen significantly increased use and excellent results, despite the high cost of this agent. Conclusion and/or Teaching Points: Various techniques have historically been used in managing type II endoleaks. Currently translumbar aneurysm sac embolization is the most frequently employed approach and use of the liquid embolic agent, Onyx continues to increase in popularity.
Educational Exhibit
S145
vascular management is suitable for patients with aneurysm rupture and hemodynamic instability. It is the desirable method of treatment in patients with multiple co-morbidities, especially malignancy. It is also associated with a decreased length of hospital stay in the elective setting. Also, failure of primary treatment can be managed with repeat percutaneous procedures. It is the ideal method of management in surgically “hard-to- access,” intra-pancreatic and peri-pancreatic territories. The majority of the pseudo-aneurysms can be successfully treated with endovascular repair. In congenitally abnormal and fragile arteries, where surgical dehiscence is likely, endovascular treatment may present a less traumatic option.
Educational Exhibit
Abstract No. 352
Evolving techniques for type II endoleak management after endovascular aneurysm repair (EVAR) J.H. Brannen, R. Oklu, S. Ganguli, G.M. Salazar, S.P. Kalva, A. Waltman, C.J. Kwolek, S. Wicky, G. Walker; Cardiovascular Imaging and Intervention, Massachusetts General Hospital, Boston, MA
Abstract No. 353
Percutaneous ultrasound guided embolization of postcatheterization femoral pseudoaneurysm using pushable fibered coil S.E. Hegab; Radiodiagnosis and Interventional Radiology, Alexandria University, Alexandria, Egypt Learning Objectives: The diagnosis of femoral pseudoaneurysm is usually straight forward and is made on the combination of physical examination and color duplex ultrasound findings.Many techniques were used for occlusion of the pseudoaneurysm, including US guided compression, thrombin injection and surgical reconstruction. Background: This study included six patients, five adult patients and one child three years old, had femoral pseudoaneurysm postcatheterization. Embolization was carried out after failure of US guided compression. The pseudoaneurysm diameter ranged from 28 to 54 mm diameter. The size of coil was one to two mm more than the diameter of the neck of the pseuodoaneurysm. Puncture of the pseudoaneurysm, coil embolization and confirming the occlusion of the peudoaneurysms were achieved using only Ultrasonography, without fluoroscopy or contrast examination. The Teflon coated puncture needle used was 16 –14 G and 15 cm length. Local anesthesia was used in the adult patients and general anaethesia for the young child patient. Clinical Findings/Procedure Details: Successful complete embolization was achieved in the six pseudoaneurysms. Immediate thrombosis of the pseudoneurysm was seen after delivery of the coil, using one coil in four lesions and two coils in the remaining two pseudoaneurysms. Bed rest for one hour after the embolization then the patient was discharged. Follow up from 3– 6 months showed complete embolization of the pseudoaneurysms, and significant regression in the size was noted in three patients. No complications were encountered inspite the patients were on anticoagulant and/or antiplatlet treatment. Conclusion and/or Teaching Points: We conclude that percutaneous US guided coil embolization of the femoral pseudoaneurysm is a safe and simple outpatient procedure that will avoid surgical reconstruction in many patients.
Educational Exhibit
Abstract No. 354
Diagnosis and management of abdominal aortic endograft infections A.A. Naiem; Radiology, University of Maryland Medical Center, Baltimore, MD Learning Objectives: This exhibit reviews the risk factors, clinical clues, and manifestations of abdominal aortic endograft infection, as well as associated cross-sectional, angiographic, and nuclear medicine imaging. Treatment options, including conservative medical, surgical and percutaneous intervention will be discussed in detail. Background: Abdominal aortic endograft infection has a reported incidence of 0.43% to 2%. However, the high mortality after diagnosis ranging from 18% to 70% demands a greater understanding of the signs and symptoms of endograft infection as well as the associated risks and its prevention. Given the infrequent occurrence of endograft infection, the diagnosis and management continues to evolve. Clinical Findings/Procedure Details: The exhibit draws upon our experience with endograft infection from an overall
Poster Sessions
Learning Objectives: Review the current management of type II endoleaks after EVAR, including intervention options and their effectiveness. Background: Post-EVAR type II endoleaks occur in up to 25% of patients due to continued aneurysm perfusion via patent branch vessels normally arising from the aorta (e.g. lumbar, inferior mesenteric arteries). These endoleaks are usually seen on surveillance imaging and have variable clinical significance. Although the majority resolve spontaneously, there is a subset in which continued perfusion causes an increase in both aneurysm sac size and rupture risk. Endoleak management continues to evolve. Whereas previously many investigators aggressively treated all type II endoleaks, a more common strategy is now one of surveillance, with intervention reserved for sac growth. Clinical Findings/Procedure Details: Preoperative embolization of major branch vessels that may potentially cause a type II endoleak is sometimes performed, but intervention is typically reserved for post-EVAR type II endoleaks causing an increase in the residual aneurysm sac volume. There are two general strategies for type II endoleak management: embolization of branch vessels perfusing the aneurysm sac and direct sac embolization. In the former, all vessels perfusing the aneurysm sac are accessed and embolized via a standard transarterial approach, with coils typically used as the embolic agent. A more common treatment is direct sac embolization via either translumbar sac puncture or a transarterial approach in which sac access is obtained by selective catherization of the feeding branch vessel(s). In either instance, the goal is eliminating the “nidus” that remains perfused (i.e. aneurysm sac). Commonly used embolic agents include coils, vascular plugs, thrombin, N-butyl cyanoacrylate and Onyx. The latter has recently seen significantly increased use and excellent results, despite the high cost of this agent. Conclusion and/or Teaching Points: Various techniques have historically been used in managing type II endoleaks. Currently translumbar aneurysm sac embolization is the most frequently employed approach and use of the liquid embolic agent, Onyx continues to increase in popularity.
Educational Exhibit