Transcaval embolization as an alternative technique for the treatment of type II endoleak after endovascular aortic aneurysm repair

Abstract

The purpose of this report is to highlight our experience with transcaval embolization (TCE) for the management of type II endoleaks (T2Es) as well as to provide a technical description of how to improve procedural safety and success. All patients underwent transfemoral venous access with transcaval puncture into the excluded aneurysm sac with coil placement and selective thrombin injection. Six patients (100% male; mean age [standard deviation] 72.7 [10.8] years) underwent TCE. Technical success was 100% with no postoperative complications. At median follow-up of 8.1 months (range, 2-22 months), two patients had persistent T2Es, with one requiring repeat TCE and the other having cessation of aneurysm growth. The TCE provides a practical alternative to transarterial or translumbar access for the management of T2E, with high degrees of technical and clinical success in this small case series. Larger patient numbers and longer-term follow-up are needed to define procedural efficacy and durability.

Operative Management of Type II Endoleaks After Aortic Endovascular Repair

“…To the best of our knowledge, the cumulative combined reported success of transarterial and translumbar procedures is ≤70%, and this is comparable to the early results of TCE [39].…”

“…Another advantage of TCE is the utilization of supine positioning, which facilitates patient comfort and concomitant arterial access allowing the confirmation of the EL, verification of EL obliteration and, if necessary, concurrent TAE. If the T2EL originates from lumbar or middle sacral vessel, we directly access the aorta via either a translumbar or TCE, with the approach dictated by the localization of the T2EL and the aorta relative to the inferior vena cava (IVC) and lumbar spine [39]. Furthermore, with TCE, the IVC is punctured through one wall instead of both, as required when the right translumbar approach is performed, and lower risk of retroperitoneal hemorrhage or inadvertent bowel injury may be anticipated [24,39].…”

“…Preoperative planning allows identification of radiographic markers (e.g., stent graft, graft bifurcation, device overlap points, or aortic wall calcifications) that may guide transcaval puncture facilitating the access to the T2EL [39]. In order to optimize needle orientation into the aneurysm sac, an intraoperative CT or CBCT can be performed [15,19].…”

“…After confirmation of successful embolization, the puncture system may be removed, and an imaging examination should be performed to determine if there is any evidence of aortocaval fistula or contrast extravasation. Usually the patient is admitted overnight and undergoes noncontrast CT at 24 h to evaluate the immediate success of embolization and to identify any complications related to the procedure [24,39]. Potential complications include the thrombophlebitis at the site of femoral percutaneous venous access, inadvertent intracaval embolization of coils, retroperitoneal hematoma, and caval-aortic fistulas [24,39].…”

“…Usually the patient is admitted overnight and undergoes noncontrast CT at 24 h to evaluate the immediate success of embolization and to identify any complications related to the procedure [24,39]. Potential complications include the thrombophlebitis at the site of femoral percutaneous venous access, inadvertent intracaval embolization of coils, retroperitoneal hematoma, and caval-aortic fistulas [24,39]. However, TCE requires a thin needle cannula and a 5 F catheter, which is quite small in caliber and only causes small holes in the caval walls.…”