Transcript Transradial Type I Endoleak Ethylene Vinyl Alcohol - SIR

Transradial Type I Endoleak Ethylene Vinyl
Alcohol Copolymer (Onyx) Embolization
Zachary L. Bercu, MD
Acknowledgements: Aaron Fischman, MD
Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai,
New York, New York. E-mail: [email protected].
Financial disclosures: None.
History
• CC: “Expanding aneurysm with suspicious post-operative
CT”
• HPI: 70 y/o male status post abdominal aortic aneurysm
(AAA) repair in 2007 admitted for expanding right lower
extremity hematoma. During admission, patient underwent
emergent proximal and distal endoleak repair with a
“snorkel” procedure, stent graft extension, left hypogastric
coil embolization and placement of a left common iliac
graft. The results of post-operative CT angiography led to
interventional radiology referral.
History
•
Relevant past medical and surgical history: Essential hypertension, hypercholesteremia, history of
abdominal aortic aneurysm status post endovascular repair (EVAR) (2007), chronic obstructive
pulmonary disease, history of myocardial infarction, coronary artery disease status post coronary
stent placement x 3, depression
•
Medications: Hydrochlorothiazide, oxycodone-acetaminophen, heparin, amlodipin, lisinopril,
docusate sodium, sennosides, setraline, diphenhydramine, ondansetron
•
Allergies: Naproxen: reaction unknown
•
Physical exam: BP: 116/62 P: 75 T: 36.4 °C RR: 19. No acute distress. No wheezing. Abdomen nontender. Extensive bilateral lower extremity and scrotal edema.
•
Relevant labs:
9.1
11.3
27.8
137
133
94
15
3.7
27
1.1
100
INR 1.1
PT 14.4
PTT 38.4
Original Endoleak Repair
CTA
Diagnosis and Panel Discussion
• Diagnosis: Persistent endoleak (type I?)
• Panel discussion: Options include:
– Open surgical repair? Patient not a great candidate (multiple comorbidities).
– Conventional endovascular repair? Complex anatomy (left external iliac
occluded), most recent attempt unsuccessful, “snorkel” already performed.
– Fenestrated endovascular graft? Not approved for use in the U.S.
– Transradial endovascular repair?
• Which embolic agents to use? Coils vs. Glue? Onyx?
• Potential complications in general: embolization failure, non-target embolization,
paralysis, “closing off” future access/options
• Onyx limitations: high radio-opacity (catheter tip obscuration), time consuming,
expensive, inability to follow on CT1
Figures 1 and 2 (cine). Digital subtraction angiography frontal full field-of-view and
magnification projections demonstrate a type IA endoleak.
Figure 3 (static). Frontal magnification view demonstrates a type IA
endoleak at the proximal edge of the stent graft at the right renal stent
snorkel.
Figures 3, 4 and 5 (static). An angled Glidewire was used to access the aneurysm sac, after which a total of 4 vials of Onyx and 23 Interlock coils were
used before the endoleak ceased filling. An Amplatzer 4 plug was placed at the proximal entry site of the endoleak to complete the seal.
Figure 6 (static). Static image from contrast angiography demonstrates no
filling of the aneurysm sac.
Figure 7 (cine). Oblique projection completion angiogram again confirms absence
of filling of the aneurysm sac. The coil/Onyx mass is highly radio-opaque.
Summary
•
•
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Follow-up: Patient discharged 3 days post-op without perioperative complication.
Patient followed with MRA.
Transradial approach well-known in cardiology literature. Common transradial
procedures at our institution include: TACE, MAA prior to Y-90, UFE, GI bleed
embolizations.
Previous studies of Onyx for type 1 endoleaks:
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–
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6 patients, 2 complications: 1 had renal artery graft and leg extension occlusions (thought to be
unrelated to Onyx) and the other had late stentgraft migration of Onyx with aneurysm rupture 18
months post-op.2
6 patients, no recurrent endoleaks.1
Conclusion: Transradial Onyx embolization of a Type 1 endoleak may be performed
successfully when other options are not available to patients.
References:
1. Chun JY, Morgan R. Transcatheter embolisation of type 1 endoleaks after endovascular aortic aneurysm repair with Onyx: when no other treatment
option is feasible. Eur J of Vasc and Endovasc Surg 2013;45(2): 141-4.
2. Henrikson O, Roos H, Falkenberg M. Ethylene vinyl alcohol copolymer (Onyx) to seal type 1 endoleak. A new technique. Vascular 2011;19(2):77-81.