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Endoleaks : graft extension or coil embolization ?. Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical University of South Carolina Charleston, SC. CANNES 2004. Endoleak. “Presence of flow at the aneurysmal sac after stent-graft treatment”.

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endoleaks graft extension or coil embolization
Endoleaks : graft extensionor coil embolization ?

Claudio Schönholz,MDAssociate Professor of RadiologyHeart and Vascular Center Medical University of South CarolinaCharleston, SC

CANNES 2004

endoleak

Endoleak

“Presence of flow at the aneurysmal sac after stent-graft treatment”

White GH, May J, Waugh RC, Chaufour X, Yu W.

Type III and type IV endoleak: toward a complete definition of blood flow in the sac

after endoluminal AAA repair. J Endovasc Surg 1998;5:305309.

slide3

Endoleak Types

  • Type I endoleak
    • Proximal or distal attachment
  • Type II endoleak
    • Retrograde branch flow
  • Type III endoleak
    • Structural defect or component junction
  • Type IV endoleak
    • Trans-graft leakage or porosity
prevention of type i endoleak
Prevention of Type I Endoleak
  • Case Selection
  • 20 % oversizing of the endograft.
  • Generous overlapping of segments.
  • Graft covers the aorta and common iliac arteries from the renal arteries down to the iliac artery bifurcation.
possible reasons of having low incidence of type i endoleaks
Possible reasons of having low incidence of Type I endoleaks:
  • No procedure was considered finished until complete sealing of the endograft was obtained.
  • Sealing of the ends and connections was achieved by applying balloon dilatation, cuffs and malleable stents at the ends ( Extra-large Palmaz)

PARODI, JC

when should type ii endoleaks be treated
WHEN SHOULD TYPE II ENDOLEAKS BE TREATED?

“If the endoleak continues to be present on the 6-month scan, there is a small chance that it will spontaneously thrombose”

  • Treat a type II endoleak if there is evidence of sac enlargement
  • Intervene if a type II endoleak is present on the 6-month scan regardless of the status of an aneurysm sac

6-month CT scan

endoleak anatomy
ENDOLEAK ANATOMY
  • Simple: small cavity and has ingress and egress from a single vessel
  • Complex: multiple ingress and egress vessels
endoleak anatomy simple
Blood enters during systole into the endoleak cavity, swirling around, leaving the endoleak cavity during diastole

Physiology similar to

a pseudo-aneurysm

May spontaneously thrombose prior to the 6-month CT scan

ENDOLEAK ANATOMY“Simple”
endoleak anatomy complex
ENDOLEAK ANATOMY“Complex”
  • Multiple ingress and egress vessels
  • Behave like arteriovenous malformations
  • Persists longer than 6 months.
slide15
How to treat Type II Endoleaks:Embolize the artery feeding the endoleak cavity by a transarterial route ?
  • This technique has proved ineffective, providing only short-term response if the sac can not be reached by the embolic agent.
  • Endoleaks will recur by recruiting additional aortic branch vessels.
slide16

The endoleak cavity acts as an “Arteriovenous malformation nidus,” and thrombosing this nidus is what provides a successful and durable response.

Richard A. Baum, MD

Do stable type II endoleaks require treatment after EVAR

Endovascular Today

type ii endoleak from ima

TYPE II ENDOLEAK FROM IMA

67 Years old High Risk Patient.

6.5 cm AAA treated 14 month ago with Gore Excluder Device.

CT scan showed Type II Endoleak from IMA and the AAA remain same size.

Indication:Endovascular Embolization

how to treat type ii endoleaks translumbar needle stick
How to treat Type II Endoleaks:translumbar needle stick ?
  • Coils and glue to completely thrombose the endoleak cavity
  • Instead of treating feeding vessels, the endoleaks themselves are being embolized
  • The connection between ingress and egress vessels, as well as the endoleak cavity, is destroyed
translumbar embolization
Translumbar Embolization

Translumbar

Gelfoam-Thrombin

6 Months FU

slide25
Translumbar Embolization of Type 2 Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms
  • 7 Patients with Type 2 Endoleak
  • 4 lumbar, 3 IMA
  • 19-gauge,20cm needle w/5fr.Teflon Sheath
  • Gianturco Coils (CooK)
  • 100% Initial Success
  • No Complications

R.A.Baum;C.Cope; R.Fairaman;J.CarpenterJ.Vasc Interv Radiol 2001;12:111-116

management of endoleaks
Management of Endoleaks
  • Type I: Immediate treatment. Balloon,Cuff, Palmaz or Conversion to Open Procedure.
  • Sealed Type I: If large Treat ,If small Watch. If size does not decrease Treat.
  • Type II: Treat after 6 months if aneurysmal size do not decrease.
  • Late Type I or III: Treat immediately.
obliteration of the aneurysmal sac in abdominal aortic aneurysms in an animal model

Obliteration of the Aneurysmal Sac in Abdominal Aortic Aneurysms in an Animal Model

Renan Uflacker,MD

slide31

Pig #3

AAA creation

Volume measurement

15 cc’s

Post Treatment

Endoleak

slide32

24 Week FU

Pig # 3

results
Results
  • The treatment of the AAA was technically successful in all animals with total exclusion of the sac
  • The AAA sac acquired a firm rubberish consistency after treatment
  • Fibrosis and calcifications were detected within the sac, mostly around the graft and in contact with the aortic wall after 4 to 6 weeks.
  • There was inflammatory reaction to the Dacron material and to the polymer (to a lesser extent)
  • Significant adhesion of the AAA with surrounding structures was observed
results1
Results
  • After 4 to 6 weeks there is a tendency for shrinkage of the AAA sac, apparently maximized by the 24th week
  • There was no sac recanalization in the follow up time ranging from 1 to 24 weeks
  • The controls at 6 and 12 weeks showed shrinkage of the AAA sac (histology not ready yet)
conclusions
Conclusions
  • pGlcNAc Glucosamine in the gel form is an unique hemostatic material
  • Promotes rapid clotting within the AAA sac
  • Also effective under systemic anticoagulation
  • Effective aneurysm sac filling with occlusion of branches

as necessary

  • Easy to use and cost effective
  • It seems to have gradual longer term absorption allowing AAA shrinkage over a period of 24 weeks but not before 6 weeks
  • Experience is necessary for volumetric measurement
  • A human trial is warranted
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