Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair Kristina A. Giles, MD, Mark F. Fillinger,

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Presentation transcript:

Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair Kristina A. Giles, MD, Mark F. Fillinger, MD, Randall R. De Martino, MD, MPH, Andrew W. Hoel, MD, Richard J. Powell, MD, Daniel B. Walsh, MD Journal of Vascular Surgery Volume 61, Issue 5, Pages 1129-1136 (May 2015) DOI: 10.1016/j.jvs.2014.12.002 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 1 Comparison of anatomy that is difficult or contraindicated for translumbar puncture (A) vs a case that might have been considered for translumbar access in the past but is now preferentially accessed by a transcaval approach (B). The green arrow indicates the line of puncture for transcaval coil embolization (TCCE) in (A), whereas the red arrows indicate pathways not suitable for translumbar access because of bone, bowel, or endograft limb obstruction. Both cases would be suitable for a transcaval approach. Journal of Vascular Surgery 2015 61, 1129-1136DOI: (10.1016/j.jvs.2014.12.002) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 Three-dimensional (3D) reconstruction (M2S) with manual addition of the inferior vena cava (IVC) and iliac vein access inserted manually (using multiline tool) to assist in access planning. The iliac vein access is typically straightforward, even with severe iliac artery tortuosity. In this case, the IVC abuts the distal aneurysm sac at an excellent location for access to the site of the endoleak. Journal of Vascular Surgery 2015 61, 1129-1136DOI: (10.1016/j.jvs.2014.12.002) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 3 Once a good site for puncture is identified, the optimal gantry angles are calculated relative to the anterior-posterior (AP) angle. The gantry angles are optimized to display a true view of the cava-aneurysm interface (“side view” shown here in yellow) and a “line-of-sight” view (blue line) to direct the puncture to the endoleak cavity (white arrow). The spine and stent graft are used as landmarks to ensure that the view is correct along with a three-dimensional (3D) reconstruction rotated to display the same gantry angle (Fig 1). LAO, Left anterior oblique; RAO, right anterior oblique. Journal of Vascular Surgery 2015 61, 1129-1136DOI: (10.1016/j.jvs.2014.12.002) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 4 We adopted the Rösch-Uchida transjugular intrahepatic portosystemic shunt set (Rösch-Uchida Transjugular Liver Access Set; Cook Medical, Bloomington, Ind) as part of our technique as it has an inner metal stiffening cannula that is coaxial to the guiding catheter. It can be shaped to abut the sac as close to a right angle as possible. The inner metal cannula on the assembly stabilizes the transjugular intrahepatic portosystemic shunt trocar or stylet, which leads the 5F inner catheter into the sac during puncture. Journal of Vascular Surgery 2015 61, 1129-1136DOI: (10.1016/j.jvs.2014.12.002) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 5 Fluoroscopic views of the alignment in the two predetermined gantry angles, using bone landmarks and stent landmarks to hit the endoleak cavity. The aneurysm is simulated in pink for reference, but overlays are typically unnecessary with appropriate planning and readily available three-dimensional (3D) reference images. The metal cannula within the guiding catheter is easily seen and is brought into position to abut the aneurysm sac as close to perpendicular as possible. Tactile feedback confirms a stable position before puncturing of the sac with the stylet/trocar using the side view. Journal of Vascular Surgery 2015 61, 1129-1136DOI: (10.1016/j.jvs.2014.12.002) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 6 Once the surgeon is satisfied that the catheter is in the endoleak cavity and backbleeding is obtained, contrast material is injected to delineate the endoleak cavity and potential target vessels. Journal of Vascular Surgery 2015 61, 1129-1136DOI: (10.1016/j.jvs.2014.12.002) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 7 Multiple coils are delivered in the desired location. Journal of Vascular Surgery 2015 61, 1129-1136DOI: (10.1016/j.jvs.2014.12.002) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 8 If necessary, liquid agents such as Onyx are considered. Journal of Vascular Surgery 2015 61, 1129-1136DOI: (10.1016/j.jvs.2014.12.002) Copyright © 2015 Society for Vascular Surgery Terms and Conditions