Tailored Sac Embolization During EVAR for Preventing Persistent Type II Endoleak

Mascoli, Chiara; Faggioli, Gianluca; Gallitto, Enrico; Pini, Rodolfo; Fenelli, Cecilia; Cercenelli, Laura; Marcelli, Emanuela; Gargiulo, Mauro

doi:10.1016/j.avsg.2021.01.118

Cited by 12 publications

(6 citation statements)

References 21 publications

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“…20 Eighteen (72%) patients were considered at high risk for type-II endoleak 21 at the preoperative evaluation and underwent to preventive AAA-sac coil embolization during the procedure. 15,22 Technical success was achieved in 25 (100%) patients; in one case, the first one of this series, a proximal unplanned cuff was required. No cases of type-I/III endoleak or renal artery coverage at the completion angiography were observed.…”

Section: Procedures Resultsmentioning

confidence: 83%

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Endovascular Treatment of Abdominal Aortic Aneurysm With Severe Angulation of Infrarenal Aortic Neck by Gore Conformable Endograft

et al. 2022

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Introduction: The aim of the study is to report a single-center experience with the Gore Excluder conformable endograft with active control system (CEXC Device, W.L. Gore and Associates, Flagstaff, AZ, USA) in abdominal aortic aneurysms (AAAs) with severe infrarenal neck angulation. Methods: All patients underwent EVAR with CEXC Device between September 2018 and 2020, were prospectively enrolled, and retrospectively analyzed. Anatomical details of the proximal aortic neck were evaluated. Early endpoints were the use of repositionability and angulation system, intraoperative unplanned cuff, technical success (TS), 30-day morbidity/mortality, and reintervention. Follow-up endpoints were type-I endoleaks, endograft migration, aortic neck dilatation, aneurismal sac shrinkage, survival (S), and freedom from reintervention (FFR). Results: Twenty-five patients were enrolled (median age: 80 [range = 60-90] years, median AAA diameter: 60 [range = 52-90] mm). All patients had severe infrarenal neck angulation (beta angle ≧ 60°), and 11 (44%) of those had neck beta angle ≧ 90°. Median infrarenal neck angle, length, and diameter were 70° (range = 60°-90°), 22 (range = 13-42) mm and 22 (range = 18-31) mm, respectively. Endograft repositioning system was employed in 15 (60%) cases and the median number of repositioning maneuvers was 1 (range:0-4). Active angulation system was used in 17 (68%) patients. The median proximal diameter of the main-body and oversize were 28 (range = 23-36) mm and 28% (range = 21%-38%), respectively. Proximal cuff was positioned in 1 (4%) patient. Technical success was achieved in all cases. Intraoperative and perioperative morbidity and mortality were 12% and 0%, respectively. Perioperative type-I/III and II endoleaks were observed in 0 and 4 (16%) patients, respectively. The median follow-up was 12 months (range: 3-30). One patient died at 12-month for AAA-unrelated causes. Abdominal aortic aneurysm-sac shrinkage and stability were observed in 9 (36%) and 15 (60%) cases, respectively. No type-I/III endoleak and reintervention occurred during the follow-up. One persistent type-II endoleak was observed. Estimated survival at 24 months was 92%. Conclusion: According to the present data, the CEXC Device allows an excellent rate of TS in severe angulated aortic neck. This preliminary data, could increase the rate of patients eligible for EVAR.

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Section: Procedures Resultsmentioning

confidence: 83%

“…Eighteen (72%) patients were considered at high risk for type-II endoleak 21 at the preoperative evaluation and underwent to preventive AAA—sac coil embolization during the procedure. 15,22…”

Section: Resultsmentioning

confidence: 99%

Endovascular Treatment of Abdominal Aortic Aneurysm With Severe Angulation of Infrarenal Aortic Neck by Gore Conformable Endograft

et al. 2022

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“…Due to our limited familiarity with NBCA, we utilized coils exclusively. According to a study by Mascoli et al [ 35 ], the effectiveness of the embolization procedure in preventing type II endoleak can be enhanced by augmenting the concentration of the implanted coils. Specifically, the neck-targeted embolization technique can produce a significant concentration of coils in the region surrounding the perigraft sac neck.…”

Section: Discussionmentioning

confidence: 99%

Selective aneurysmal sac neck-targeted embolization during endovascular repair of abdominal aortic aneurysm with hostile neck anatomy

Zhang,

Tang,

Wang

et al. 2024

J Cardiothorac Surg

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Purpose To evaluate the efficacy and safety of selective aneurysmal sac neck-targeted embolization in endovascular aneurysm repair (EVAR) in patients with a hostile neck anatomy (HNA). Materials and methods Between October 2020 and June 2022, patients with an abdominal aortic aneurysm (AAA) and HNA who underwent EVAR with a low-profile stent graft and a selective aneurysmal sac neck-targeted embolization technique were analysed. An HNA was defined by the presence of any of the following parameters: infrarenal neck angulation > 60°; neck length < 15 mm; conical neck; circumferential calcification ≥ 50%; or thrombus ≥ 50%. Before occluding the entire aneurysm during the procedure, a buddy wire was loaded prophylactically into the sac through the contralateral limb side. If a type Ia endoleak (ELIa) occurred and persisted despite adjunctive treatment such as balloon moulding or cuff extension, this preloaded wire could be utilized to enable a catheter to reach the space between the stent graft and sac neck to perform coil embolization. In the absence of ELIa, the wire was simply retracted. The primary outcome of this study was freedom from sac expansion and endoleak-related reintervention during the follow-up period; secondary outcomes included technical success and intraoperative and in-hospital postoperative complications. Results Among the 28 patients with a hostile neck morphology, 11 (39.5%) who presented with ELIa underwent intraprocedural treatment involving sac neck-targeted detachable coil embolization. Seventeen individuals (60.7%) of the total patient population did not undergo coiling. All patients in the coiling group underwent balloon moulding, and 2 patients additionally underwent cuff extension. In the noncoiling group, 14 individuals underwent balloon moulding as a treatment for ELIa, while 3 patients did not exhibit ELIa during the procedure. The coiling group showed longer operating durations (81.27 ± 11.61 vs. 70.71 ± 7.17 min, P < 0.01) and greater contrast utilization than the noncoiling group (177.45 ± 52.41 vs. 108.24 ± 17.49 ml, P < 0.01). In the entire cohort, the technical success rate was 100%, and there were no procedure-related complications. At a mean follow-up of 18.6 ± 5.2 months (range 12–31), there were no cases of sac expansion (19 cases of sac regression, 67.86%; 9 cases of stability, 32.14%) or endoleak-related reintervention. Conclusions Selective aneurysmal sac neck-targeted embolization for the treatment of ELIa in AAA patients with an HNA undergoing EVAR is safe and may prevent type Ia endoleak and related sac expansion after EVAR.

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“…The classic approach involves transarterial embolisation of the IMA (via the colic artery) or the lumbar artery, where embolisation may target only the problematic vessel, the aneurysmal sac, or both the aneurysm sac and the vessel. The technique entails inserting a catheter into the aorta, typically through the femoral or brachial artery [44,45]. In some cases, if access through the femoral or brachial artery is impossible or inadequate, the catheter can be inserted by directly pricking a branch of the internal iliac artery (superior gluteal artery) in a translumbar approach [46].…”

Section: Treatment Of Patients With Type II Endoleaksmentioning

confidence: 99%

Prevention and management of type II endoleaks after endovascular aneurysm repair

Pietrzak,

Maciąg,

Terlecki

2023

Acta Angiologica

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Endovascular aneurysm repair (EVAR) has emerged as a pivotal technique in managing abdominal aortic aneurysms. As with any medical intervention, EVAR poses inherent risks of complications. Among various post-EVAR complications, a major one is endoleaks, characterised by periprosthetic leakage. Various types of endoleaks exist, with type II being the most commonly observed, resulting from blood reperfusion into the aneurysm sac through the lumbar and/or inferior mesenteric artery (IMA), median sacral, or accessory renal arteries. Due to the low-pressure nature of type II endoleaks, consequences may range from patients being asymptomatic to experiencing life-threatening situations. The risk of aneurysm rupture in cases of isolated type II endoleaks is relatively low, estimated at 0.5% to 2.4%. Therefore, routine observation is generally recommended, and intervention is reserved for situations where there is a persistent increase in the aneurysm sac diameter by more than 5 mm over 6 months or the occurrence of other complications, such as rupture of the aneurysm sac. If detected during the procedure, type II endoleaks often resolve spontaneously, making immediate treatment unnecessary. Factors contributing to the persistence of such leaks include an active IMA, a high number and diameter of active lumbar arteries, and ongoing anticoagulant treatment. The long-term effects of type II endoleaks vary, with the aneurysm sac shrinking in 25% of patients, remaining unchanged in the majority of patients (50-70%), and enlarging in a few patients (12%). Treatment options, if needed, encompass diverse methods such as embolisation of the IMA or lumbar arteries using coils, occluders, or tissue adhesives, injection of polymers directly into the aneurysmal sac, or laparoscopic clipping of the IMA and lumbar arteries. However, the efficacy of these methods varies, with the aneurysm continuing to grow in 60% of patients, often necessitating repeat procedures or even graft removal and traditional surgery. Despite extensive research on type II endoleaks, therapeutic considerations remain unresolved. Moreover, the importance of intervention, optimal timing of procedures, most effective diagnostic methods, and treatment modalities for type II endoleaks remain controversial.

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Tailored Sac Embolization During EVAR for Preventing Persistent Type II Endoleak

Cited by 12 publications

References 21 publications

Endovascular Treatment of Abdominal Aortic Aneurysm With Severe Angulation of Infrarenal Aortic Neck by Gore Conformable Endograft

Endovascular Treatment of Abdominal Aortic Aneurysm With Severe Angulation of Infrarenal Aortic Neck by Gore Conformable Endograft

Selective aneurysmal sac neck-targeted embolization during endovascular repair of abdominal aortic aneurysm with hostile neck anatomy

Prevention and management of type II endoleaks after endovascular aneurysm repair

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