BackgroundEndovascular aortic repair (EVAR) requires further intervention in 20-30 % of cases, often due to type II endoleak (T2EL).  Management options for T2EL include transarterial embolization, direct puncture (DP), or transcaval embolization.  We report the case of an 80-year-old man with T2EL who successfully underwent DP embolization. MethodsEmbolization by DP was performed with a transpedicular approach using an isocenter puncture (ISOP) method.  An isocenter marker (ICM) was placed at a site corresponding to the aneurysm sac on fluoroscopy in two directions (frontal and lateral views).  A vertebroplasty needle was inserted tangentially to the ICM under fluoroscopy and advanced to the anterior wallmore » of the vertebral body.  A 20 cm-length, 20-G-PTCD needle was inserted through the outer needle of the 13-G needle and advanced to the ICM.  Sac embolization using 25 % N-buty-2-cyanoacrylate diluted with Lipiodol was performed.  After complete embolization, rotational DA confirmed good filling of the sac with Lipiodol.  The outer cannula and 13-G needle were removed and the procedure was completed. ResultsThe patient was discharged the next day.  Contrast-enhanced computed tomography 1 and 8 months later showed no Lipiodol washout in the aneurysm sac, no endoleak recurrence, and no expansion of the excluded aneurysm. ConclusionDP with a transpedicular approach using ISOP may be useful when translumbar and transabdominal approaches prove difficult.«  less

PurposeThis prospective study was designed to assess the diagnostic value of magnetic resonance angiography (MRA) with blood-pool contrast agent (gadofosveset) in the detection of type-II endoleak after endovascular aortic repair (EVAR).MethodsThirty-two patients with aortic aneurysms who had undergone EVAR were included in this study.  All patients were examined by dual-phase computed tomography angiography (CTA) as well as MRA with gadofosveset in the first-pass and steady-state phases.  Two independent readers evaluated the images of CTA and MRA in terms of endoleak type II, feeding vessel, and image quality. ResultsMedian follow-up-time after EVAR was 22 months (range 4 to 59).  Endoleak type IImore » was detected by CTA in 12 of 32 patients (37.5%); MRA detected endoleak in all of these patients as well as in another 9 patients (n = 21, 65.6%), of whom the endoleaks in 6 patients showed an increasing diameter.  Most endoleaks were detected in the steady-state phase (n = 14).  The decrease in diameter of the aneurysmal sac was significantly greater in the patients without a visible endoleak that was visible on MRA (P = 0.004).  In the overall estimation of diagnostic accuracy, MRA was judged superior to CTA in 66% of all examinations. ConclusionMRA with gadofosveset appeared superior to CTA, and has higher diagnostic accuracy, in the detection of endoleak after EVAR.«  less

The purpose of this study was to report our experience in treating type II endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms.  Two hundred eighteen patients underwent EVAR with a Zenith stent-graft from January 2000 to December 2005.  During a follow-up period of 4.5 {+-} 2.3 years, solely type II endoleak was detected in 47 patients (22%), and 14 of them underwent secondary interventions to correct this condition.  Ten patients had transarterial embolization, and four patients had translumbar/transabdominal embolization.  The embolization materials used were coils, thrombin, gelatin, Onyx (ethylene-vinyl alcohol copolymer), and glue.  Disappearance of the endoleak withoutmore » enlargement of the aneurysm sac after the first secondary intervention was achieved in only five of these patients (5/13).  One patient without surveillance imaging was excluded from analyses of clinical success.  After additional interventions in four patients and the spontaneous disappearance of type II endoleak in two patients, overall clinical success was achieved in eight patients (8/12).  One patient did not have surveillance imaging after the second secondary intervention.  Clinical success after the first secondary intervention was achieved in two patients (2/9) in the transarterial embolization group and three patients (3/4) in the translumbar embolization group.  The results of secondary interventions for type II endoleak are unsatisfactory.  Although the small number of patients included in this study prevents reliable comparisons between groups, the results seem to favor direct translumbar embolization in comparison to transarterial embolization.«  less

PurposeThis study was designed to identify parameters on CT angiography (CTA) of type II endoleaks following endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), which can be used to predict the subsequent need for reinterventions. MethodsWe retrospectively identified 62 patients with type II endoleak who underwent early CTA in mean 3.7 ± 1.9 days after EVAR.  On the basis of follow-up examinations (mean follow-up period 911 days; range, 373–1,987 days), patients were stratified into two groups: those who did (n = 18) and those who did not (n = 44) require reintervention.  CTA characteristics, such as AAA, endoleak, as well as nidus dimensions, patency of the inferior mesentericmore » artery, number of aortic branch vessels, and the pattern of endoleak appearance, were recorded and correlated with the clinical outcome. ResultsUnivariate and receiver operating characteristic curve regression analyses revealed significant differences between the two groups for the endoleak volume (surveillance group: 1391.6 ± 1427.9 mm{sup 3}; reintervention group: 3227.7 ± 2693.8 mm{sup 3}; cutoff value of 2,386 mm{sup 3}; p = 0.002), the endoleak diameter (13.6 ± 4.3 mm compared with 25.9 ± 9.6 mm; cutoff value of 19 mm; p < 0.0001), the number of aortic branch vessels (2.9 ± 1.2 compared with 4.2 ± 1.4 vessels; p = 0.001), as well as a “complex type” endoleak pattern (13.6 %, n = 6 compared with 44.4 %, n = 8; p = 0.02).ConclusionsEarly CTA can predict the future need for reintervention in patients with type II endoleak.  Therefore, treatment decision should be based not only on aneurysm enlargement alone but also on other imaging characteristics.«  less

PurposeTo assess the relationship between the systolic sac pressure index (SPI) and the presence of endoleaks 12 months after endovascular abdominal aortic aneurysm repair (EVAR).Materials and MethodsWe performed a single-center prospective trial of consecutively treated patients.  SPI (calculated as systolic sac pressure/systolic aortic pressure) was measured by catheterization immediately after EVAR.  Contrast-enhanced computed tomography was scheduled 12 months after EVAR to detect possible endoleaks. ResultsData were available for 34 patients who underwent EVAR for an AAA.  Persisting type II endoleak was found in 8 patients (endoleak-positive group) but not in the other 26 patients (endoleak-negative group).  The mean ± standard deviation SPI was significantly greatermore » in the endoleak-positive group than in the endoleak-negative group (0.692 ± 0.048 vs. 0.505 ± 0.081, respectively; P = .001).  Receiver-operating characteristic curve analysis revealed that an SPI of 0.638 was the optimum cutoff value for predicting a persistent endoleak at 12 months with high accuracy (0.971; 33/34), sensitivity (1.00), and specificity (0.962) values.  The mean change in AAA diameter was −4.28 ± 5.03 mm and 2.22 ± 4.54 mm in patients with SPI of <0.638 or ≥0.638, respectively (P = .002).ConclusionPatients with an SPI of ≥0.638 immediately after EVAR were more likely to have a persistent type II endoleak at 12 months with an accuracy of 0.971, and showed increases in aneurysm sac diameter compared with patients with an SPI of <0.638.«  less