Embolization of a Type II Endoleak Using...

Embolization of a Type II Endoleak Using Onyx

Resident(s): Sumeet Bahl, MD

Fellow(s): Steve Steer, MD

Attending(s): Adie Friedman, MD; Joseph Shams, MD

Program/Dept(s): Mt. Sinai St. Luke’s-Roosevelt; Mt. Sinai Beth Israel

CHIEF COMPLAINT & HPI

▪Chief Complaint and/or reason for consultation ▪Status post EVAR with enlarging type II endoleak, request for embolization.

▪History of Present Illness ▪91-year-old female with PMH of incidental 6cm infrarenal AAA status post EVAR (2007) complicated by type Ia endoleak treated with a fenestrated endograft at an outside hospital.

▪Follow up CT showed growth of aneurysm sac to 8cm due to a type IIb endoleak, treated with glue/coil embolization of feeding right hypogastric artery branches x2 by Vascular Surgery.

▪Follow up outside CT showed persistent type II endoleak and the patient was admitted for Onyx embolization of feeding arteries by IR.

▪The patient denied abdominal or back pain, lower extremity paresthesias or motor weakness, or fecal or urinary incontinence.

RELEVANT HISTORY

▪Past Medical History ▪AAA, hypertension, hyperlipidemia, chronic anemia, hepatitis C

▪Past Surgical History ▪EVAR (2007), fenestrated endograft placement for type Ia endoleak, coil/glue embolization of type IIb endoleak (Oct. 2014), left total knee arthroplasty (2004), colon resection (2003), open appendectomy (1940s)

▪Family & Social History ▪No history of tobacco or significant EtOH use

▪Son had ruptured AAA s/p open repair

▪Review of Systems: As per hpi, otherwise negative ▪Medications ▪Aspirin 81mg, Carvedilol, Lisinopril, Amlodipine, Simvastatin, EPO injections, Alprazolam, Trazodone

▪Allergies: NKDA

DIAGNOSTIC WORKUP

▪Physical Exam ▪Gen: AOx3

▪CVS: RRR, S1/S2+

▪Lungs: CTA b/l

▪Abd: soft, nontender/nondistended, no palpable pulsatile mass

▪Ext: b/l dp/pt pulses palpable

▪Laboratory Data ▪WBC 4.7 H/H 8.2/25.5 Plt 174

▪Creatinine 1.2

▪PT 14.8 PTT 41.6 INR 1.2

Triple-phase CT Angiogram of Abdomen/Pelvis

▪Lumbar arteries and median sacral artery are the feeding vessels.

DIAGNOSIS

▪Type IIb endoleak of infrarenal abdominal aortic aneurysm endograft

QUESTION SLIDE

1) The most common contributing vessels to a type II endoleak are:

A: Celiac artery and inferior mesenteric artery.

B: Superior mesenteric artery and inferior mesenteric artery.

C: Inferior mesenteric artery and lumbar arteries.

D: Superior mesenteric artery and internal iliac arteries.

CORRECT!






CONTINUE WITH CASE

SORRY, THAT’S INCORRECT!






CONTINUE WITH CASE

INTERVENTION

▪CT-guided aortic puncture and vascular sheath placement x2

▪ Translumbar aortogram

▪Fluoroscopy-guided Onyx and coil embolization of type IIb endoleak feeding vessels

INTERVENTION (CONT.)

▪CT-guided aortic puncture and vascular sheath placement x2


▪Translumbar aortogram


▪Fluoroscopy-guided Onyx and coil embolization of type IIb endoleak feeding vessels

QUESTION SLIDE

2) Ethylene vinyl alcohol (EVOH) liquid embolic aka Onyx is sometimes preferred for endoleak embolization because it has no risk of non-target embolization compared to cyanoacrylate glue.

A: True

B: False

CORRECT!


A: True

B: False. Onyx has a real, but uncommon, risk of nontarget embolization minimized by slow injections and use of the high viscosity form when appropriate.

CONTINUE WITH CASE

SORRY, THAT’S INCORRECT!


A: True

B: False. Onyx has a real, but uncommon, risk of nontarget embolization minimized by slow injections and use of the high viscosity form when appropriate.

CONTINUE WITH CASE

CLINICAL FOLLOW UP

▪Post-procedure day 1: CT abdomen/pelvis without PO/IV contrast

▪1-month post-embolization triple-phase CTA is pending

SUMMARY & TEACHING POINTS

▪Endovascular aortic repair (EVAR) first published by Parodi et al in 1991 in the Annals of Vascular Surgery

▪Major complication of EVAR is endoleak: “The persistence of blood flow outside the lumen of the endoluminal graft but within an aneurysm sac…” – Baum et al, 2004

▪Incidence of endoleak after EVAR is about 33% ▪Most common is type II ~80%

▪Risk factors: tortuous anatomy, many branch vessels, ?anticoagulation

▪Common post-EVAR surveillance: 1 mo, 6 mos, and annually using CT, US, or angio


▪Endoleak classification: ▪Type I: attachment site leaks

▪A: proximal

▪B: distal

▪C: iliac occluder

▪Rx: immediate balloons, stents, or stent-graft extension

▪Type II: collateral vessel leaks (lumbar arteries, IMA, or median sacral artery)

▪A: simple (single vessel)

▪B: complex (2 or more vessels)

▪Rx: delayed placement of coils, glue, EVOH (Onyx)

▪Type III: graft failure

▪A: midgraft hole

▪B: junctional leak or disconnect

▪C: other (suture holes, etc.)

▪Rx: immediate covering with stent-graft

▪Type IV: graft wall porosity

▪Rx: usually none

▪Type V: endotension

▪+/- endoleak

▪+/- treatment


▪Approach to embolization of type II endoleak ▪Translumbar via CT (our approach) or fluoroscopy

▪Transarterial via fluoroscopy

▪Pre-op IMA coil embolization before EVAR to decrease type II endoleak and sac enlargement

▪Agents used in embolization of type II endoleak ▪Platinum coils, N-butyl cyanoacrylate glue, and/or ethylene vinyl alcohol (EVOH aka Onyx)

▪Onyx (liquid embolic agent) = EVOH dissolved in dimethyl sulfoxide (DMSO)

+ tantalum contrast powder

•Initially used for intracranial aneurysms

▪Still has risk of non-target embolization but is delivered in slower, more

controlled manner than glue

•Khaja et al, 2014 studied Onyx with or without coil/glue/Amplatzer plug after

TEVAR and EVAR with good result

REFERENCES

▪Baum, Richard A., Jeffrey P. Carpenter, Michael A. Golden, Omaida C. Velazquez, Timothy W. Clark, S. William Stavropoulos, Constantine Cope, and Ronald M. Fairman. "Treatment of Type 2 Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms: Comparison of Transarterial and Translumbar Techniques." Journal of Vascular Surgery 35.1 (2002): 23-29. Mt. Sinai Library. Web. 18 Dec. 2014.

▪Baum, Richard A., William Stavropoulos, Ronald M. Fairman, and Jeffrey P. Carpenter. "Endoleak: What Works?" Journal of Vascular and Interventional Radiology 15.2 (2004): P217-225. Mt. Sinai Library. Web. 18 Dec. 2014.

▪Guimaraes, Marcelo, and Mathew Wooster. "Onyx (Ethylene-vinyl Alcohol Copolymer) in Peripheral Applications." Seminars in Interventional Radiology 28.3 (2011): 350-56. Mt. Sinai Library. Web. 18 Dec. 2014.

▪Khaja, Minhaj S., Auh W. Park, Warren Swee, Avery J. Evans, J. Fritz Angle, Ulku C. Turba, Saher S. Sabri, and Alan H. Matsumoto. "Treatment of Type II Endoleak Using Onyx with Long-term Imaging Follow-up." Cardiovascular and Interventional Radiology 37 (2014): 613-22. Mt. Sinai Library. Web. 18 Dec. 2014.

▪Martin, Michael M., Bart L. Dolmatch, Peter D. Fry, and Lindsay S. Machan. "Treatment of Type II Endoleaks with Onyx." Journal of Vascular and Interventional Radiology 12 (2001): 629-32. Mt. Sinai Library. Web. 18 Dec. 2014.

▪Ward, Thomas J., Stuart Cohen, Aaron M. Fischman, Edward Kim, Francis S. Nowakowski, Sharif H. Ellozy, Peter L. Faries, Michael L. Marin, and Robert A. Lookstein. "Preoperative Inferior Mesenteric Artery Embolization before Endovascular Aneurysm Repair: Decreased Incidence of Type II Endoleak and Aneurysm Sac Enlargement with 24-month Follow-up." Journal of Vascular and Interventional Radiology 24.1 (2013): 49-55. Mt. Sinai Library. Web. 18 Dec. 2014.

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