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Direct Percutaneous Sac Injection for Treatment of a Thoracic Type II Endoleak
Volume 24
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Number 7
’
July
’
2013
Bleeding into the cyst resulted in another serious condition, ie, infection of the cyst, which required prolonged intensive care treatment, including administration of antibiotic agents, percutaneous drainage, and spigot placement in the bronchus. In summary, we report a case of bleeding into a pulmonary cyst as a result of pulmonary RF ablation. The bleeding subsequently resulted in respiratory arrest. Although the patient was resuscitated, the cyst subsequently became infected, and the patient required prolonged treatment.
Direct Percutaneous Sac Injection for Treatment of a Thoracic Type II Endoleak From: Andreas S. Kreusch Shaun Samuels, MD James F. Benenati, MD Melanie Schernthaner, MD Heiko Uthoff, MD Baptist Cardiac and Vascular Institute (A.S.K., S.S., J.F.B., M.S., H.U.) 8900 N. Kendall Dr. Miami, FL 33176; and Department of Angiology (H.U.) University Hospital Basel Basel, Switzerland
Editor: Thoracic endovascular aneurysm repair has become the treatment of choice for many chronic and acute pathologic processes of the descending thoracic aorta, including treatment of ruptured thoracic aneurysms. Endoleaks remain a nuisance associated with endovascular repair and have been reported in as many as 29% of cases (1). Abdominal direct percutaneous sac injection (DPSI) has been described as a feasible alternative treatment option if a standard transarterial approach is not possible or has previously failed to resolve a type II endoleak (2). Here we describe an interesting case of evaluation and treatment of a thoracic endoleak with the use of a direct percutaneous approach for selective bronchial artery and aneurysm sac embolization. A 77-year-old man with a history of open ascending aortic aneurysm repair and aortic bioprosthetic valve replacement initially presented with an upper descending thoracic aortic dissection (Stanford type B, DeBakey type III), which had ruptured into the mediastinum. The patient underwent emergent percutaneous endograft repair. Despite deployment of four EXCLUDER None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.03.024
1071
REFERENCES 1. Hiraki T, Tajiri N, Mimura H, et al. Pneumothorax, pleural effusion, and chest tube placement after radiofrequency ablation of lung tumors: Incidence and risk factors. Radiology 2006; 241:275–283. 2. Vaughn C, Mychaskiw G, Sewell P. Massive hemorrhage during radiofrequency ablation of a pulmonary neoplasm. Anesth Analg 2002; 94: 1149–1151. 3. Sakurai J, Mimura H, Gobara H, Hiraki T, Kanazawa S. Pulmonary artery pseudoaneurysm related to radiofrequency ablation of lung tumor. Cardiovasc Intervent Radiol 2010; 33:413–416. 4. Yamakado K, Takaki H, Takao M, et al. Massive hemoptysis from pulmonary artery pseudoaneurysm caused by lung radiofrequency ablation: successful treatment by coil embolization. Cardiovasc Intervent Radiol 2010; 33:410–412.
endografts (W.L. Gore and Associates, Flagstaff, Arizona) a small type IA endoleak persisted and could not be treated by using a standard femoral approach as a result of a highly tortuous thoracic aorta. By using a transapical access as a “bailout” approach, the type I endoleak was excluded successfully with deployment of a Palmaz 5010 stent. Follow-up computed tomographic (CT) angiography at 6 months revealed contrast medium within the aneurysm sac, likely indicating a type II endoleak superior and posterior to the aortic arch (Figure, a). The patient was placed prone on the procedure table, and cone-beam CT (Allura FD-20; Philips, Best, The Netherlands) was obtained to determine the best region to be accessed (Figure, a, shows planned puncture route). After local anesthesia was obtained, a 22-gauge Chiba needle was advanced on a paraspinal route directly into the thoracic aneurysm sac under fluoroscopy guidance by using landmarks of the thoracic endograft for reference. Bloody backflow indicated successful needle entry into the aneurysm sac, as also confirmed by lateral views. A sac injection was performed with approximately 5 mL of contrast agent to evaluate the aneurysm sac and type of endoleak. A large outflowing bronchial artery was observed, but there was no sign of a concurrent type I endoleak (Figure, b). At this time, an AccuStick introducer system (Boston Scientific, Natick, Massachusetts) was used to exchange the needle for a 6-F sheath. A 0.018-inch, 70º gold-tip angled Glidewire (Terumo, Somerset, New Jersey) was used for selective probing of the bronchial artery, and a 2.4-F Progreat microcatheter (Terumo) was advanced. Coil embolization with six 3–4-mm 2-cm Tornado microcoils (Cook, Bloomington, Indiana) was performed. A slurry of Gelfoam (Baxter, Deerfield, Illinois) mixed in 50/50 contrast medium along with 225 U of thrombin was then carefully injected into the aneurysm sac until stasis within the sac was observed (Figure, c). The catheter was removed, and manual pressure was applied at the puncture site to achieve hemostasis. Five-week and 6month CT follow-up demonstrated no signs of recurrent endoleak, with shrinkage of the aneurysm sac (maximal axial diameter before intervention, 80.2 mm; after 6 mo, 47.2 mm) and mediastinal hematoma (Figure, d).
1072
’
Letters to the Editor
Kreusch et al
’
JVIR
Figure. (a) Sagittal maximum-intensity projection of baseline CT angiogram shows contrast medium in the aneurysm sac superior and posterior to the thoracic endograft. The arrow indicates the puncture route for DPSI. (b) Initial sac injection confirmed a type II endoleak via a bronchial artery. (c) Final sac injection with stasis of the contrast agent after bronchial artery coil deposition and sac injection of a Gelfoam/thrombin slurry. (d) Sagittal maximum-intensity projection of 6-month follow-up CT angiogram shows significant aneurysm sac shrinkage, resolution of periaortic hematoma, and no evidence of an endoleak.
Type II endoleaks caused by patent covered intercostal and bronchial arteries are observed in approximately 10% of patients treated with thoracic endovascular aneurysm repair, with continued sac expansion and potential sac rupture seen in some patients. In one study (1), spontaneous endoleak thrombosis was observed in 29% of patients (two of seven) during a mean follow-up of 17 months ⫾ 15, and continued sac expansion was observed in the majority of cases under observational management. In the patient described here, there was concern that a residual or concurrent type I endoleak might be present, as characterization of the endoleak type on standard CT angiography is not always precise (2). Although DPSI has become an accepted approach for the treatment of postoperative endoleak after endovascular aneurysm repair (2), few case reports have reported that this approach might be also feasible to treat thoracic endoleaks (3,4). DPSI with sac injection would not only help to clarify the endoleak characteristics, but would also be the only remaining
realistic treatment option for any type of endoleak in the patient described here. Indeed, sac injection confirmed a type II endoleak via a bronchial artery, and the patient could be treated in the same session with a single percutaneous sac puncture. Similar to the concept of endovascular malformation therapy, a combined treatment of the inflow/outflow and the aneurysm sac itself was performed. There is no consensus on the best embolic agent for this application, and a combination of n-butyl cyanoacrylate glue, Ethiodol, Trufill (Codman, Raynham, Massachusetts), and/or platinum coils has been reported (3,4). After successful selective coil embolization of the bronchial artery in the present case, a slurry of Gelfoam and thrombin for embolization of the aneurysm sac was used, with an excellent short-term result. In summary, DPSI is a feasible bailout technique for evaluation and treatment of endoleaks not only in the abdominal but also in the thoracic location.
Volume 24
’
Number 7
’
July
’
2013
REFERENCES 1. Parmer SS, Carpenter JP, Stavropoulos SW, et al. Endoleaks after endovascular repair of thoracic aortic aneurysms. J Vasc Surg 2006; 44:447–452. 2. Uthoff H, Katzen BT, Gandhi R, Pena C, Benenati JF, Geisbüsch P. Direct percutaneous sac injection for postoperative endoleak treatment after endovascular aortic aneurysm repair. J Vasc Surg 2012; 56:965–972.
Interventional Radiologic Placement of Denver Pleuroperitoneal Shunt for Refractory Chylothorax From: Vishal Khiatani, MD Ari Isaacson, MD Hyeon Yu, MD Joseph Stavas, MD Department of Radiology University of North Carolina at Chapel Hill 101 Manning Dr. Chapel Hill, NC 27599
Editor: We describe successful treatment of a chylothorax refractory to conventional management by imageguided placement of a Denver pleuroperitoneal shunt (CareFusion, Waukegan, Illinois). A 49-year-old man with esophageal adenocarcinoma underwent Ivor–Lewis esophagectomy and thoracic duct ligation. In the immediate postsurgical period, chest radiographs
1073
3. Klein S, Picus D. Thoracic type II endoleak embolization using direct percutaneous puncture. Cardiovasc Intervent Radiol 2011; 35: 1249–1252. 4. Stavropoulos SW, Tucker J, Carpenter JP. Thoracic endoleak embolization using a direct percutaneous puncture of the endoleak through lung parenchyma. J Vasc Interv Radiol 2009; 20:1248–1251.
demonstrated an effusion with large-volume chylous fluid draining from his thoracostomy tube, with daily output ranging from 0.5 to 3.5 L (Fig. 1). The chylothorax did not improve after a fat-restricted diet, total parenteral nutrition, repeat surgical thoracic duct ligation, and pleurodesis. Additional procedures, including intranodal lymphangiography with cisterna chyli embolization (postoperative days 16 and 17) and thoracic duct needle disruption with alcohol ablation (postoperative day 31), were also performed, without resolution of the effusion. Forty-nine days after the initial surgery and hospitalization, a consensus decision was made to percutaneously create a pleuroperitoneal shunt. The procedure was performed under general anesthesia in the interventional radiology suite. Preprocedural ampicillin/sulbactam (Unasyn; Pfizer, New York, New York) was administered. A 3-cm transverse incision was made over the ninth to 11th ribs in the right lateral chest
Figure 1. Chest radiograph demonstrates moderate-sized right pleural effusion after clamping trial of surgical chest tube (arrow).
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.03.012
Figure 2. Fluoroscopic image demonstrates reservoir overlying lateral chest wall (open arrow) with pleural end of shunt tubing at the base of the right lung. The peritoneal portion of the catheter is partially visualized (black arrow).
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Number 7
’
July
’
2013
Bleeding into the cyst resulted in another serious condition, ie, infection of the cyst, which required prolonged intensive care treatment, including administration of antibiotic agents, percutaneous drainage, and spigot placement in the bronchus. In summary, we report a case of bleeding into a pulmonary cyst as a result of pulmonary RF ablation. The bleeding subsequently resulted in respiratory arrest. Although the patient was resuscitated, the cyst subsequently became infected, and the patient required prolonged treatment.
Direct Percutaneous Sac Injection for Treatment of a Thoracic Type II Endoleak From: Andreas S. Kreusch Shaun Samuels, MD James F. Benenati, MD Melanie Schernthaner, MD Heiko Uthoff, MD Baptist Cardiac and Vascular Institute (A.S.K., S.S., J.F.B., M.S., H.U.) 8900 N. Kendall Dr. Miami, FL 33176; and Department of Angiology (H.U.) University Hospital Basel Basel, Switzerland
Editor: Thoracic endovascular aneurysm repair has become the treatment of choice for many chronic and acute pathologic processes of the descending thoracic aorta, including treatment of ruptured thoracic aneurysms. Endoleaks remain a nuisance associated with endovascular repair and have been reported in as many as 29% of cases (1). Abdominal direct percutaneous sac injection (DPSI) has been described as a feasible alternative treatment option if a standard transarterial approach is not possible or has previously failed to resolve a type II endoleak (2). Here we describe an interesting case of evaluation and treatment of a thoracic endoleak with the use of a direct percutaneous approach for selective bronchial artery and aneurysm sac embolization. A 77-year-old man with a history of open ascending aortic aneurysm repair and aortic bioprosthetic valve replacement initially presented with an upper descending thoracic aortic dissection (Stanford type B, DeBakey type III), which had ruptured into the mediastinum. The patient underwent emergent percutaneous endograft repair. Despite deployment of four EXCLUDER None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.03.024
1071
REFERENCES 1. Hiraki T, Tajiri N, Mimura H, et al. Pneumothorax, pleural effusion, and chest tube placement after radiofrequency ablation of lung tumors: Incidence and risk factors. Radiology 2006; 241:275–283. 2. Vaughn C, Mychaskiw G, Sewell P. Massive hemorrhage during radiofrequency ablation of a pulmonary neoplasm. Anesth Analg 2002; 94: 1149–1151. 3. Sakurai J, Mimura H, Gobara H, Hiraki T, Kanazawa S. Pulmonary artery pseudoaneurysm related to radiofrequency ablation of lung tumor. Cardiovasc Intervent Radiol 2010; 33:413–416. 4. Yamakado K, Takaki H, Takao M, et al. Massive hemoptysis from pulmonary artery pseudoaneurysm caused by lung radiofrequency ablation: successful treatment by coil embolization. Cardiovasc Intervent Radiol 2010; 33:410–412.
endografts (W.L. Gore and Associates, Flagstaff, Arizona) a small type IA endoleak persisted and could not be treated by using a standard femoral approach as a result of a highly tortuous thoracic aorta. By using a transapical access as a “bailout” approach, the type I endoleak was excluded successfully with deployment of a Palmaz 5010 stent. Follow-up computed tomographic (CT) angiography at 6 months revealed contrast medium within the aneurysm sac, likely indicating a type II endoleak superior and posterior to the aortic arch (Figure, a). The patient was placed prone on the procedure table, and cone-beam CT (Allura FD-20; Philips, Best, The Netherlands) was obtained to determine the best region to be accessed (Figure, a, shows planned puncture route). After local anesthesia was obtained, a 22-gauge Chiba needle was advanced on a paraspinal route directly into the thoracic aneurysm sac under fluoroscopy guidance by using landmarks of the thoracic endograft for reference. Bloody backflow indicated successful needle entry into the aneurysm sac, as also confirmed by lateral views. A sac injection was performed with approximately 5 mL of contrast agent to evaluate the aneurysm sac and type of endoleak. A large outflowing bronchial artery was observed, but there was no sign of a concurrent type I endoleak (Figure, b). At this time, an AccuStick introducer system (Boston Scientific, Natick, Massachusetts) was used to exchange the needle for a 6-F sheath. A 0.018-inch, 70º gold-tip angled Glidewire (Terumo, Somerset, New Jersey) was used for selective probing of the bronchial artery, and a 2.4-F Progreat microcatheter (Terumo) was advanced. Coil embolization with six 3–4-mm 2-cm Tornado microcoils (Cook, Bloomington, Indiana) was performed. A slurry of Gelfoam (Baxter, Deerfield, Illinois) mixed in 50/50 contrast medium along with 225 U of thrombin was then carefully injected into the aneurysm sac until stasis within the sac was observed (Figure, c). The catheter was removed, and manual pressure was applied at the puncture site to achieve hemostasis. Five-week and 6month CT follow-up demonstrated no signs of recurrent endoleak, with shrinkage of the aneurysm sac (maximal axial diameter before intervention, 80.2 mm; after 6 mo, 47.2 mm) and mediastinal hematoma (Figure, d).
1072
’
Letters to the Editor
Kreusch et al
’
JVIR
Figure. (a) Sagittal maximum-intensity projection of baseline CT angiogram shows contrast medium in the aneurysm sac superior and posterior to the thoracic endograft. The arrow indicates the puncture route for DPSI. (b) Initial sac injection confirmed a type II endoleak via a bronchial artery. (c) Final sac injection with stasis of the contrast agent after bronchial artery coil deposition and sac injection of a Gelfoam/thrombin slurry. (d) Sagittal maximum-intensity projection of 6-month follow-up CT angiogram shows significant aneurysm sac shrinkage, resolution of periaortic hematoma, and no evidence of an endoleak.
Type II endoleaks caused by patent covered intercostal and bronchial arteries are observed in approximately 10% of patients treated with thoracic endovascular aneurysm repair, with continued sac expansion and potential sac rupture seen in some patients. In one study (1), spontaneous endoleak thrombosis was observed in 29% of patients (two of seven) during a mean follow-up of 17 months ⫾ 15, and continued sac expansion was observed in the majority of cases under observational management. In the patient described here, there was concern that a residual or concurrent type I endoleak might be present, as characterization of the endoleak type on standard CT angiography is not always precise (2). Although DPSI has become an accepted approach for the treatment of postoperative endoleak after endovascular aneurysm repair (2), few case reports have reported that this approach might be also feasible to treat thoracic endoleaks (3,4). DPSI with sac injection would not only help to clarify the endoleak characteristics, but would also be the only remaining
realistic treatment option for any type of endoleak in the patient described here. Indeed, sac injection confirmed a type II endoleak via a bronchial artery, and the patient could be treated in the same session with a single percutaneous sac puncture. Similar to the concept of endovascular malformation therapy, a combined treatment of the inflow/outflow and the aneurysm sac itself was performed. There is no consensus on the best embolic agent for this application, and a combination of n-butyl cyanoacrylate glue, Ethiodol, Trufill (Codman, Raynham, Massachusetts), and/or platinum coils has been reported (3,4). After successful selective coil embolization of the bronchial artery in the present case, a slurry of Gelfoam and thrombin for embolization of the aneurysm sac was used, with an excellent short-term result. In summary, DPSI is a feasible bailout technique for evaluation and treatment of endoleaks not only in the abdominal but also in the thoracic location.
Volume 24
’
Number 7
’
July
’
2013
REFERENCES 1. Parmer SS, Carpenter JP, Stavropoulos SW, et al. Endoleaks after endovascular repair of thoracic aortic aneurysms. J Vasc Surg 2006; 44:447–452. 2. Uthoff H, Katzen BT, Gandhi R, Pena C, Benenati JF, Geisbüsch P. Direct percutaneous sac injection for postoperative endoleak treatment after endovascular aortic aneurysm repair. J Vasc Surg 2012; 56:965–972.
Interventional Radiologic Placement of Denver Pleuroperitoneal Shunt for Refractory Chylothorax From: Vishal Khiatani, MD Ari Isaacson, MD Hyeon Yu, MD Joseph Stavas, MD Department of Radiology University of North Carolina at Chapel Hill 101 Manning Dr. Chapel Hill, NC 27599
Editor: We describe successful treatment of a chylothorax refractory to conventional management by imageguided placement of a Denver pleuroperitoneal shunt (CareFusion, Waukegan, Illinois). A 49-year-old man with esophageal adenocarcinoma underwent Ivor–Lewis esophagectomy and thoracic duct ligation. In the immediate postsurgical period, chest radiographs
1073
3. Klein S, Picus D. Thoracic type II endoleak embolization using direct percutaneous puncture. Cardiovasc Intervent Radiol 2011; 35: 1249–1252. 4. Stavropoulos SW, Tucker J, Carpenter JP. Thoracic endoleak embolization using a direct percutaneous puncture of the endoleak through lung parenchyma. J Vasc Interv Radiol 2009; 20:1248–1251.
demonstrated an effusion with large-volume chylous fluid draining from his thoracostomy tube, with daily output ranging from 0.5 to 3.5 L (Fig. 1). The chylothorax did not improve after a fat-restricted diet, total parenteral nutrition, repeat surgical thoracic duct ligation, and pleurodesis. Additional procedures, including intranodal lymphangiography with cisterna chyli embolization (postoperative days 16 and 17) and thoracic duct needle disruption with alcohol ablation (postoperative day 31), were also performed, without resolution of the effusion. Forty-nine days after the initial surgery and hospitalization, a consensus decision was made to percutaneously create a pleuroperitoneal shunt. The procedure was performed under general anesthesia in the interventional radiology suite. Preprocedural ampicillin/sulbactam (Unasyn; Pfizer, New York, New York) was administered. A 3-cm transverse incision was made over the ninth to 11th ribs in the right lateral chest
Figure 1. Chest radiograph demonstrates moderate-sized right pleural effusion after clamping trial of surgical chest tube (arrow).
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.03.012
Figure 2. Fluoroscopic image demonstrates reservoir overlying lateral chest wall (open arrow) with pleural end of shunt tubing at the base of the right lung. The peritoneal portion of the catheter is partially visualized (black arrow).