Treatment of type II endoleak with a transcatheter transcaval approach: Results at 1- year follow-up Giancarlo Mansueto, MD, Daniela Cenzi, MD, Alberto.

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Treatment of type II endoleak with a transcatheter transcaval approach: Results at 1- year follow-up Giancarlo Mansueto, MD, Daniela Cenzi, MD, Alberto Scuro, MD, Leonardo Gottin, MD, Andrea Griso, MD, Andrew A. Gumbs, MD, Roberto Pozzi Mucelli, MD Journal of Vascular Surgery Volume 45, Issue 6, Pages 1120-1127 (June 2007) DOI: 10.1016/j.jvs.2007.01.063 Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 1 Transcaval direct puncture of the aneurysm sac. A, A right transjugular percutaneous access is used to place a 10F sheath and a curved guiding cannula into the inferior vena cava. B, Anteroposterior projection of cavography and (C) lateral projections highlight the system’s wedging to caval walls at the selected puncture site. D, The aneurysm sac is punctured with the flexible needle. Journal of Vascular Surgery 2007 45, 1120-1127DOI: (10.1016/j.jvs.2007.01.063) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 2 Transcaval transcatheter embolization of the aneurysm sac (same patient as in Fig 1). A, A hydrophilic wire is enrolled inside the sac (arrowheads). B, A diagnostic angiography is performed, contrast medium fills the aneurysm sac, and the endoleak is highlighted. C, Embolization is realized under fluoroscopic guidance by placing coils and filling the sac with thrombin (arrows). D, Cavography through the introducer sheath doe not demonstrate lesions at the site of puncture. Coils and stable contrast medium are highlighted inside the sac (arrows). Journal of Vascular Surgery 2007 45, 1120-1127DOI: (10.1016/j.jvs.2007.01.063) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 3 Intrasac pressure monitoring during transcatheter transcaval embolization. A, A systolic/diastolic wave is demonstrated inside the sac (122/118 mm Hg). B, After approximately 3 minutes from the injection of 1 mL thrombin, the waveform disappeared, with a stable high pressure (121 mm Hg). After another 2 mL of thrombin, waiting 3 minutes after every single injection before remeasuring pressure, a progressive decrease in pressure is observed. C, Pressure is about 48 mm Hg after 2 mL thrombin, and (D) 7 mm Hg after 3 mL thrombin. Journal of Vascular Surgery 2007 45, 1120-1127DOI: (10.1016/j.jvs.2007.01.063) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 4 A computed tomography (CT) scan 24 hours after transcatheter transcaval embolization (TEE) and at 12 months. A, Unenhanced CT scan 24-hours after the treatment highlights stable contrast (asterisks) and gas bubbles (arrowhead) inside the aneurysm sac, whose main diameter is 85 mm. That confirms that the aneurysm sac was reached through the transcaval puncture and also that there was an immediate success of the embolization. B, At 12-months, an enhanced delayed-phase CT scan demonstrates no recurrence of endoleaks. Furthermore, the main diameter of the aneurysm sac is reduced to 75 mm. TTE clinical success is thus achieved. Of interest is that the sac walls are thicker and hyperdense. This finding may be related to the development of a stable thrombus and consequent fibrosis. Journal of Vascular Surgery 2007 45, 1120-1127DOI: (10.1016/j.jvs.2007.01.063) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions