Embolization:
Type II endoleaks Fig. 21 are usually managed by transarterial approach:
a) Transarterial approach: a catheter is placed in the vessel of origin (in this case,
the superior mesenteric artery) Fig. 22 Fig. 23
Microcatheters are pulled through collateral vessels into the vessel that communicates with the aneurysm sac (in this case the inferior mesenteric artery) [Haulon S,
J Vasc Surg 2001]
Metallic coils are then used to embolize the vessel near its communication with the aneurysm sac to block the leak Fig. 24
This way,
only one supply of the endoleak is embolized.
Inflow can then shift to a lumbar branch and recanalize the endoleak,
causing recurrence of the endoleak.
[Baum RA,
J Vasc Surg 2002]
A modification of the transarterial method involves manipulation of a microcatheter through the superior mesenteric artery and inferior mesenteric artery into the endoleak cavity itself.
The entire endoleak cavity and the feeding vessel can then be embolized,
which may provide a more durable result.
Another example,
with an endoleak caused by the left hypogastric artery with an approach through the right epigastric inferior artery.
The epigastric inferior artery is catheterized Fig. 25 and the aferent artery to the leak is reached with a microcatheter Fig. 26 embolizing at this point with metallic coils Fig. 27
b) A percutaneous translumbar approach can also be used [Stavropoulos SW,
J Vasc Interv Radiol 2003]
Endoleaks are spatially related to bony landmarks and the stent-graft itself (via CTA)
With the patient in the prone position,
and under fluoroscopy,
we guide a 19-gauge 20-cm needle with a 5-F catheter into the endoleak (with a left or right flank approach)
Once positioned in the endoleak,
we can use the translumbar catheter to embolize the endoleak.
The catheter must be placed in the patent portion of the endoleak,
not in the thrombosed portion of the aneurysm.
We can check the proper positioning of the catheter with a manual injection of contrast (there must be a free and pulsatile flow of blood to lumbar arteries or the inferior mesenteric artery)
The most commonly used embolic agents are stainless steel and platinum coils.
Liquid embolic agents such as n-butyl cyanoacrylate have also been used with success [Stavropoulos J Vasc Interv Radiol 2005]
Stent-graft placement:
Repair of type I (and type III) endoleaks is usually made by securing the attachment sites with angioplasty balloons,
stents,
or stent-graft extensions Fig. 11 Fig. 12 Fig. 13
As an example,
in a case of EVAR with placement of a fenestrated endoprothesis under the origin of both renal arteries Fig. 14 a type I endoleak was seen in the proximal end of the endoprothesis due to lack of attachment to both renal arteries origin Fig. 15 Fig. 10
First left and afterwards right renal artery were catheterized Fig. 16 to perform the same procedure: A microcatheter was pulled through the renal artery Fig. 17 to place a stent-graft in the confluence of the renal artery with the aortic endoprothesis Fig. 18
Finally,
posterior balloon dilatation was performed to secure the attachment between the renal artery grafts and the endoprothesis Fig. 19 Fig. 20