Percutaneous ultrasound-guided thrombin injection for endoleaks: an alternative

Outcome and technical evolution of type 2 endoleak embolization with ethylene-vinyl-alcohol copolymer

PURPOSE

This study aims to evaluate the safety and efficacy of novel approaches to type 2 endoleak access for the purpose of embolization using ethylene-vinyl-alcohol copolymer (EVOH) in patients with abdominal aortic aneurysm (AAA) sac expansion post endovascular abdominal aortic repair (EVAR).

METHODS

A retrospective review of 43 consecutive patients (mean age = 80.2 ± 6.7 years) who underwent 52 embolization procedures for type 2 endoleaks using EVOH was performed at a single institution. Catheterization of the endoleaks was achieved using the transarterial (TA) and direct translumbar approaches (DTL), in addition to the novel direct transabdominal (DTA) and perigraft (PG) approaches. Endpoints included technical success of endoleak catheterization, technical success of endoleak embolization, endoleak persistence, endoleak recurrence, AAA sac area change, and adverse events.

RESULTS

The TA, DTL, DTA, and PG approaches were used 25, 2, 14, and 19 times respectively, including nine procedures where a combination of approaches was used. The technical success rate of endoleak embolization was 98%. Five patients developed recurrent type 2 endoleaks, while five patients developed a type 1 endoleak. The persistent endoleak rate at a mean initial follow-up of 3 months was 34%. At a mean follow-up of 18 months, 58% of patients demonstrated absence of an endoleak, and 71% showed freedom from AAA sac enlargement. No major adverse events were recorded.

CONCLUSION

The DTA and PG approaches were safe and effective in this cohort of patients undergoing embolization of type 2 endoleaks with EVOH.

Ultrasound Assisted On-Table Management of Type III Endoleak at Endovascular Repair of Isolated Giant Common Iliac Aneurysm

Objectives

This report presents the endovascular treatment of a large isolated common iliac artery aneurysm, focusing on the use of on table ultrasonography to characterise and treat an early endoleak that could not be defined by angiography alone.

Report

A 58 year old man presented with an asymptomatic, large (13cm) left common iliac artery aneurysm (LCIAA) whilst being investigated for change in bowel habit. This was treated successfully via a percutaneous approach using left internal iliac embolisation followed by endovascular aneurysm repair (EVAR) with deployment of an aorto-uni-iliac converter system from the LCIA origin to the external iliac artery. A non-characterised endoleak at the end of the procedure was shown to be a type IIIb endoleak by application of immediate on table ultrasonography, allowing immediate supplementary targeted stent graft deployment to cover the leaking segment.

Discussion

The patient was discharged uneventfully and will remain on follow up. On table ultrasonography allowed both localisation and characterisation of an immediate intra-procedural endoleak and confirmed cessation of the endoleak with supplementary stent grafting and thrombosis within the sac.

Conclusions

Isolated CIAA is rare, and endovascular therapy is appropriate for them, given that open surgery, whilst feasible, carries a high morbidity and mortality risk. Application of on-table ultrasound allows definition and targeted treatment of endoleaks, reducing the need for further intervention at a later stage, and thus also reducing the risk of continued pressurisation of the large sac post-EVAR till the next surveillance episode.

•

Isolated common iliac artery aneurysms (CIAAs) are very rare.

•

They can be asymptomatic but have a high risk of rupture.

•

Open repair is high risk and associated with high morbidity/mortality.

•

This paper highlights successful endovascular repair of a giant isolated CIAA.

•

On table ultrasound helps immediately to characterise and treat endoleaks at EVAR.

The Safety of Using Large Amount (30 cc) of Onyx (Ethylene-vinyl Alcohol Copolymer) for the Treatment of Large Type II Endoleak after Endovascular Repair of Abdominal Aortic Aneurysm

Endovascular aneurysm repair (EVAR) is associated with late complications including the development of endoleaks as major complications. Type II endoleak is the consequence of collateral retrograde flow from the aortic branches; generally from the lumbar arteries, inferior mesenteric artery, or middle sacral artery. The method and the ideal timing for the treatment of endoleaks remain controversial. We are presenting a case of successful treatment of a large type II endoleak using embolization with large amount of Onyx copolymer via a percutaneous transfemoral route without any adverse outcome. A significant advantage of Onyx as opposed to glue is that it may be injected for a long period of time (20-60 minutes) with a lower risk for microcatheter entrapment. This case report suggests that much higher amount of Onyx can safely be used if needed to seal large endoleaks without adverse event.

Evaluation of tablet ultrasound for routine abdominal interventional procedures

AIM

The aim of the study was to establish if a novel tablet ultrasound (US) may replace a high-end US machine during routine interventional radiology activities.

MATERIALS AND METHODS

Thirty consecutive patients were evaluated by two operators comparing the performance of the new US tablet system (VISIQ, Philips Healthcare) against a high-end US system (iU22, Philips Healthcare) using a curved probe (C5-2). A structured questionnaire was used to rank on a 4-point scale the ability of each system to locate a target as detected by previous examinations and visualize needles and path during an interventional procedure. Necessity for conversion from the tablet US to the high-end US system was registered; body mass index (BMI) was annotated for each patient.

RESULTS

Agreement between the operators was found for every patient. Mean patient BMI was 25 (range 17-34). Image quality of the tablet US was considered insufficient in 1 case to visualize the target and in another case to visualize the needle. Mean target image quality was superior with the high-end US system, while needle visibility scored higher with the tablet US. Conversion to the high-end system was registered in 40 % of cases: in most cases (66.6 %) the decision was due to the absence of a dedicated needle guide for the tablet US.

CONCLUSIONS

The novel tablet US was found to provide sufficient image quality for the majority of routine interventional procedures. Dedicated accessories and additional experience with this new generation US device may be needed to replace bulky high-end US systems.

Rupture of the infrarenal abdominal aortic aneurysm (AAA) following an endovascular aneurysm repair (EVAR) due to an isolated type II endoleak

We present a case of an elderly man with the persisting type II endoleak following endovascular aneurysm repair. In a view of the multiple comorbidities, the patient was denied an open elective repair. However, when presented with a ruptured aneurismal sac, he underwent an emergency open abdominal aortic aneurysm repair. Overall, the patient has made a good postoperative recovery.

Miscellaneous pharmaceutical agents in interventional radiology

Interventional radiologists employ a wide variety of drugs on a daily basis to improve patient experiences and outcomes during interventional procedures. The expectation is for the interventionalist to be well-versed in all pharmaceuticals used in the interventional suite. In this article, the authors review the following classes of common miscellaneous pharmaceutical agents used in interventional radiology: vasodilators, vasoconstrictors, antiemetics, bowel antiperistalsis agents, and prothrombotics.

Quality improvement guidelines for imaging detection and treatment of endoleaks following endovascular aneurysm repair (EVAR)

Major concerns after aortic aneurysm repair are caused by the presence of endoleaks, which are defined as persistent perigraft flow within the aortic aneurysm sac. Diagnosis of endoleaks can be performed with various imaging modalities, and indications for treatment are based on further subclassifications. Early detection and correct classification of endoleaks are crucial for planning patient management. The vast majority of endoleaks can be treated successfully by interventional means. Guidelines for Imaging Detection and Treatment of endoleaks are described in this article.

Minimally invasive application of thrombin in the treatment of pseudoaneurysms following open aortic surgery

BACKGROUND

Anastomotic leaks are uncommon complications following aortic surgery. To avoid the morbidity associated with a second surgical procedure, minimally invasive techniques have become increasingly popular.

PURPOSE

To evaluate the feasibility and safety of thrombin in interventional treatment of postoperative pseudoaneurysms.

MATERIAL AND METHODS

CT-guided percutaneous injection was chosen in four cases. Endovascular access using an occlusion balloon catheter placed in the orifice of the pseudoaneurysm was utilized in one case.

RESULTS

The average volume of all pseudoaneurysms was 178 ± 190 mL with a volume of the patent lumen of 25 ± 28 mL. All aneurysms thrombosed after injection of 600 ± 237 IU of thrombin. During the follow-up period of an average of 10 months all pseudoaneurysms remained occluded.

CONCLUSION

Our series demonstrates the feasibility of thrombin in the treatment of aortic anastomotic pseudoaneurysms. In combination with occlusion balloon catheters, even wide-necked pseudoaneurysms may be treated successfully. However, further investigations are warranted.

Percutaneous transabdominal approach for the treatment of endoleaks after endovascular repair of infrarenal abdominal aortic aneurysm

Objective

The purpose of this study was to evaluate the technical feasibility and clinical efficacy of percutaneous transabdominal treatment of endoleaks after endovascular aneurysm repair.

Materials and Methods

Between 2000 and 2007, six patients with type I (n = 4) or II (n = 2) endoleaks were treated by the percutaneous transabdominal approach using embolization with N-butyl cyanoacrylate with or without coils. Five patients underwent a single session and one patient had two sessions of embolization. The median time between aneurysm repair and endoleak treatment was 25.5 months (range: 0-84 months). Follow-up CT images were evaluated for changes in the size and shape of the aneurysm sac and presence or resolution of endoleaks. The median follow-up after endoleak treatment was 16.4 months (range: 0-37 months)

Results

Technical success was achieved in all six patients. Clinical success was achieved in four patients with complete resolution of the endoleak confirmed by follow-up CT. Clinical failure was observed in two patients. One eventually underwent surgical conversion, and the other was lost to follow-up. There were no procedure-related complications.

Conclusion

The percutaneous transabdominal approach for the treatment of type I or II endoleaks, after endovascular aneurysm repair, is an alternative method when conventional endovascular methods have failed.

The use of thrombin in the radiology department

Thrombin is a naturally occurring coagulation protein that converts soluble fibrinogen into insoluble fibrin and plays a vital role in the coagulation cascade and in turn haemostasis. Thrombin also promotes platelet activation. In the last few years, there has been a rapid increase in the use of thrombin by radiologists in a variety of clinical circumstances. It is best known for its use in the treatment of pseudoaneurysms following angiography. However, there are now a variety of cases in the literature describing the treatment of traumatic, inflammatory and infected aneurysms with thrombin in a variety of locations within the human body. There have even been recent reports describing the use of thrombin in conventional aneurysms as well as ruptured aneurysms. Its use has also been described in the treatment of endoleaks (type II) following aneurysm repair. In nearly all of these cases, treatment with thrombin requires imaging guidance. Recently, thrombin has also been used as a topical treatment post-percutaneous intervention to reduce or stop bleeding. Most radiologists have only a limited knowledge of the pharmacodynamics of thrombin, its wide range of utilisation and its limitations. Apart from a few case reports and case series, there is little in the radiological literature encompassing the wide range of applications that thrombin may have in the radiology department. In this review article, we comprehensively describe the role and pathophysiology of thrombin, describing with examples many of its potential uses. Techniques of usage as well as pitfalls and limitations are also described.

Translumbar Type II Endoleak Repair Using Angiographic CT

Translumbar embolization of type II endoleaks after endovascular abdominal aneurysm repair has been proved to be effective. One challenge of this approach is the choice of the most suitable image guiding modality. For needle placement, cross-sectional imaging under computed tomographic (CT) guidance is preferable. For embolization, fluoroscopy is the modality of choice for most interventionalists. A new technology can acquire CT-like images by rotating an angiographic, flat-panel detector of a C-arm around the patient. This technology allows a combination of fluoroscopic and CT guidance within the angiographic suite. The authors describe the successful use of a combination of fluoroscopy and angiographic CT in three cases of translumbar type II endoleak embolization.