transabdominal direct sac puncture embolization of type ii ... · • median fluoroscopic time =...
TRANSCRIPT
![Page 1: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/1.jpg)
Transabdominal Direct Sac Puncture Embolization of Type II
Endoleaks after EVARRebecca Zener*, MD, DABR, FRCPC
George Oreopoulos, MD, MSc, FRCSC
Robert Beecroft, MD, FRCPC
Dheeraj Rajan, MD, FRCPC, FSIR
Jeff Jaskolka, MD, FRCPC
Kong Teng Tan, MD, FRCS, FRCR, FRCPCDivision of Interventional Radiology, University Health Network, Toronto, Canada
![Page 2: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/2.jpg)
Disclosure
Speaker name: Rebecca Zener
I do not have any potential conflict of interest
![Page 3: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/3.jpg)
Study Objective
• To evaluate the safety and efficacy of trans-abdominal direct puncture for embolization of T2E following EVAR
![Page 4: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/4.jpg)
Methods
• Review of 29 patients (4F, 25M)
• Mean age = 79y
• Underwent 32 trans-abdominal direct sac puncture embolizations of T2E following EVAR
• NBCA only (43.8%)
• NBCA and coils (37.5%)
• Onyx with or without glue/coils (18.8%)
![Page 5: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/5.jpg)
T2E: Indications for Treatment
• > 5 mm sac diameter enlargement
• > 5% increase in sac volume
• Ruptured AAA treated with EVAR that develops T2E
![Page 6: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/6.jpg)
Type II Endoleak (T2E): Principles of Treatment
• Aneurysm sac behaves like an AVM
• Filling the aneurysm sac prevent shunting between feeding arteries
• Embolizing feeding arteries = essential
• Coiling feeding artery alone is NOT sufficient
![Page 7: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/7.jpg)
T2E Pre-Trans-Abdominal Direct Sac Puncture Embolization
![Page 8: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/8.jpg)
Pre-Procedure Management
• Out-patient procedure
• Fasting overnight
• Antibiotics: Ancef and Flagyl IV
![Page 9: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/9.jpg)
Patient supine
Press hard with probe
Aim 18 g needle deep & posterior,target: endoflow
![Page 10: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/10.jpg)
Bowel Moves Out of the Way Easily
Supine Prone
![Page 11: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/11.jpg)
Transabdominal Direct Puncture
![Page 12: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/12.jpg)
Technique & Embolic Agents
• Advance microcatheter as close as possible to largest feeding arteries (i.e. L4-5 lumbars) and coil them if possible
• N-butyl cyanoacrylate (NBCA) glue and lipiodol mixture
• 1 : 3-4 glue: lipiodol
• Onyx
• Inject dilute Onyx 18 to start until feeders embolized
• Then fill the sac with Onyx 34
![Page 13: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/13.jpg)
If Antegrade Flow in IMA…Coil Near Its Origin to Prevent Distal
Colonic Embolization
![Page 14: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/14.jpg)
Embolize the feeding vessels then fill the sac
• Example using Onyx
![Page 15: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/15.jpg)
Methods
• Manual segmentation of aneurysm sac volume pre- and post- embolization on CTA using Aquarius Terarecon
• Primary outcome: freedom of aneurysmgrowth
• ≤5% aneurysm sac volume change on follow-up CT imaging
• Secondary outcomes: technical success and complication rate
![Page 16: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/16.jpg)
29 patients
Clinical follow-up withDoppler U/S or CTA:
21 patients (72%)
17.2 months
CTA follow-up:
20 patients (69%)
7.1 months
No follow-up:
8 patients (28%)
Mean follow-up duration
![Page 17: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/17.jpg)
Results
• Primary Technical Success = 97% (28/29)
• Complete endoleak embolization on fluoroscopy
• Freedom of aneurysm growth = 80% (16/20)
• Based on aneurysm sac volume on CTA
• Clinical success with aneurysm stability without endoflow on U/S = 81% (17/21)
![Page 18: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/18.jpg)
Change in aneurysm sac volume (mL)
318.2 311.3
Pre Post
1% decrease in aneurysm sac volume (p>.05)
![Page 19: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/19.jpg)
Technical and Safety Results (n=32)
• Technical parameters
• Median fluoroscopic time = 11.3 minutes
• Median procedure time = 90 minutes
• Safety
• No aneurysm or procedure related mortality
• 9.4% complication rate (3/32)
• 1 non-target embolization neuromuscular injury to psoas resolved within ~6 months
• 2 self-limiting rectus sheath hematomas
![Page 20: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/20.jpg)
Conclusion
• Percutaneous transabdominal direct puncture for type II endoleak embolization
• Safe
• Efficacious
• 80% freedom of aneurysm growth based on volume
• Efficient
• No CT required for access
• Easy to gain entry into endoleak and feeders
• Low procedure and fluoroscopic time
• Accepted by patients (comfort)
![Page 21: Transabdominal Direct Sac Puncture Embolization of Type II ... · • Median fluoroscopic time = 11.3 minutes • Median procedure time = 90 minutes • Safety • No aneurysm or](https://reader034.vdocument.in/reader034/viewer/2022050605/5fac1b560c622d69cd0f5b1b/html5/thumbnails/21.jpg)
Transabdominal Direct Sac Puncture Embolization of Type II
Endoleaks after EVARRebecca Zener*, MD, DABR, FRCPC
George Oreopoulos, MD, MSc, FRCSC
Robert Beecroft, MD, FRCPC
Dheeraj Rajan, MD, FRCPC, FSIR
Jeff Jaskolka, MD, FRCPC
Kong Teng Tan, MD, FRCS, FRCR, FRCPCDivision of Interventional Radiology, University Health Network, Toronto, Canada