Presentation

Transcubital Onyx Embolization of a Type 2 Endoleak after EVAR

Transcubital access to the patent IMA which is responsible for a Type 2 Endoleak.

Comments

    Excellent demostration of the devices and materials, step-by-step, really illuminating for me, thank you very much Özgun. Just three short questions: 1) what is your preference criteria for Onyx over other embolizing agents, such as coils or NBCA, coils or other agents? 2) apart from the feeding vessel (i.e. IMA), do you usually take care of any outflow vessels (eg lumbar arteries)? 3) What is your standard visualization protocol of follow-up after embolozation? I usually have difficulties to detect any angiographic leak reccurence with CTAngiography postoperatively due to artifacts caused by the embolic agent…

    Thank you for your kind words.
    Here are my answers to your questions.
    1) Usually, I use for the treatment of Type2-EL Onyx. In case of bigger vessels eventually coils as an add-on. In case of a Type1-EL for example due to a gutter-EL after CHEVAR or periscope-technique, we have good experiences with coils (Penumbra or Concerto). We prefer to treat classic Type 1 EL with an extension, a type 1a eventually with the support of an endoanchor (Heli-FX), a type 1b with an iliac-side-branch if possible.
    2) Generally, we try to embolize as little as possible and to treat exactly the feeding branch. Especially the treatment of the IMA has to be done precious. We are afraid of embolizing bigger or accompanying vessels like the superior rectal artery or the complete internal iliac. Even in the lumbar territory you never know the exact effects of the embolization. Till now we luckily never had a spinal ischemia, so we are a bit more generous. If we can’t reach the main feeding vessel branch, we accept a distance embolization of lumbar arteries with Onyx.
    3) Our postop protocol requires a Duplex-scan after three months and a CT-scan after six months if the embolization was successful. Our main objective is the aneurysm diameter. If this is stable or decreasing, we plan the next CT-scan every 12 months, if not again after six months. If the artifacts are enormous, we check ta possible endoleak with an invasive angiogram.

    I hope I could answer your questions. Feel free to contact me any time. Thank you for your interest.

    Dear Özgün,
    as it seems that the diameter of the aneurysm is the only (main) factor that influences your desicion making process, would you change you follow up protocol from CT scan to duplex ultrasound?

    Of course, the aneurysm diameter is the most important factor for a treatment indication. But a regularly CT-Scan detects an upcoming Type-1-EL due to a neck degeneration or stent-migration. I think the duplex scan is not a proper tool to detect those problems. So for me, an EVAR-patient normally needs a continuous follow up including a CT-scan.
    The exception might be the patient with a complete decreasing of its aneurysm diameter down to the graft diameter or the patient with long aneurysm-necks, which are able to be examined accurately by a KM enhanced duplex-ultrasound

    Maybe I expressed myself not clearly. An Endoleak Type 1 or 3 is of course detectable by a duplex-scan very well. What I meant is something different. I am talking about an upcoming problem (I think I wrote that word in my former reply). Degenerations of the necks or a beginning stent migration weren’t the endpoints of this study. Just the detection of the endoleak was examined. This is not what I am talking about.
    For me, a CT scan is still the only tool we have, which can detect anatomically or graft-related problems before a Type 1 or 3 Endoleak is existing. You can’t get this information from a duplex scan.

    I hope, you understand now my comment. Thank you for mentioning the studies above, but they are really well known. Even for me.

    Warm regards

    Özgün allow me to disagree. In a metaanalysis published in BJS (Br J Surg. 2012 Nov;99(11):1514-23.) duplex ultrasound was found to be specific for detection of types 1 and 3 endoleaks. Moreover, in a single center experience published from Antonello et al (J Vasc Surg. 2013 Oct;58(4):886-93.) EVAR was associated with a higher decline in renal function compared to open repair. The post-operative survaillance with CT scan might be the main reason for this finding.

    Maybe I expressed myself not clearly. An Endoleak Type 1 or 3 is of course detectable by a duplex-scan very well. What I meant is something different. I am talking about an upcoming problem (I think I wrote that word in my former reply). Degenerations of the necks or a beginning stent migration weren’t the endpoints of this study. Just the detection of the endoleak was examined. This is not what I am talking about.
    For me, a CT scan is still the only tool we have, which can detect anatomically or graft-related problems before a Type 1 or 3 Endoleak is existing. You can’t get this information from a duplex scan.

    I hope, you understand now my comment. Thank you for mentioning the studies above, but they are really well known. Even for me.

    Warm regards

    MD Michel Bosiers
    June 7, 2018

    Also a MRI might help you in detecting resilient endoleaks after embolisation. You don’t have the same problem with the tantalum powder in onyx as in a CT scan. What do you think?

    MR would not be an adequate solution for patients treated with stainless steel stent grafts. Ayhow, I am not sure that information regarding ”neck degeneration” in the absence of an endoleak is relevant for the everyday practise.

    MD Michel Bosiers
    June 8, 2018

    That is correct, however Stainless steel endorafts are just a minority, since in infrarenal EVAR, currently (to my knowledge) only the Zenith (cook) uses stainless steel, except for its low profile device which has nitinol stents.

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