Evaluation and Treatment of Suspected Type II Endoleaks in Patients with Enlarging Abdominal Aortic Aneurysms

Abstract

Purpose To evaluate angiographic diagnosis and embolotherapy of patients with enlarging abdominal aortic aneurysms and computed tomographic (CT) diagnosis of type II endoleak. Materials and Methods A retrospective review was performed of all patients referred to a single vascular and interventional radiology section from January 1, 2003, to June 1, 2011, with a diagnosis of enlarging aneurysm and type II endoleak. Twenty-five patients underwent 40 procedures between 12 and 82 months after endograft insertion (mean, 48 mo) for diagnosis and/or treatment of endoleaks. Results Type II endoleaks were treated with cyanoacrylate, coils, and ethylene vinyl alcohol copolymer in 16 patients. Technical success rate was 88% (14 of 16 patients) and clinical success rate was 100% (16 of 16 patients). Aneurysm growth was arrested in all cases over a mean follow-up of 27.5 months (range, 6 – 88 mo). Endoleaks in nine patients were misclassified on CT; two had type I endoleaks and seven had type III endoleaks. Four of the nine patients (two type I endoleaks and two type III endoleaks) were correctly classified after initial angiography. The other five type III endoleaks were correctly classified on CT after coil embolization of the inferior mesenteric artery. Direct embolization was performed via sac puncture with ethylene vinyl alcohol copolymer in two of the latter five patients and eliminated endoleaks in both. Conclusions Aneurysm growth caused by type II endoleaks was arrested by embolization. CT misclassification occurred relatively commonly; type III endoleaks purported to be type II endoleaks were found in 28% of patients (seven of 25).

Evidence for Ethylene-Vinyl-Alcohol-Copolymer Liquid Embolic Agent as a Monotherapy in Treatment of Endoleaks

“…3 One study included patients with multiple attempts to treat endoleaks including attempts involving coils and Onyx. 4 This study did, however, have six patients where, following failed attempts at other techniques, direct sac puncture and Onyx embolization was employed. These cases are identifiable and have been included.…”

Type II endoleak after endovascular aneurysm repair

“…CT 33 Massis et al 39 2012 Sac expansion ≥ 5 mm within 6 months, sac > 6 cm 4 † n.s. 95 Sheehan et al 40 2004 Persistent leak ≥ 6 months 18 CT 28 Aziz et al 41 2012 Persistent type II endoleak ± sac expansion 23 CT 42 Conrad et al 42 2009 Persistent type II endoleak with sac expansion 35 CT 832 Funaki et al 43 2012 Persistent type II endoleak with sac expansion ≥ 5 mm 27·5 C T 2 5…”

“…In addition, no single vessel embolized offered better protection against secondary intervention or sac expansion. One study reported outcomes for both a transarterial approach and direct sac puncture 43 .…”

Ethylene Vinyl Alcohol Copolymer (Onyx) Embolization for Acute Hemorrhage: A Systematic Review of Peripheral Applications

“…The characteristics that make EVOH copolymer effective in the treatment of cerebrovascular lesions may benefit hemorrhagic lesions elsewhere in the body, and peripheral nonneurologic applications are becoming more accepted (2)(3)(4). Most of the literature on Onyx focuses on neurologic lesions (5,6) and chronic aortic endoleaks (7,8); the remaining literature on the topic largely comprises case reports and case series. In this study, we systematically reviewed the existing literature on the use of EVOH copolymer to treat acute hemorrhage outside of the head and neck to determine its efficacy and safety for use in peripheral lesions.…”