Presentation on theme: "Transradial Type I Endoleak Ethylene Vinyl Alcohol Copolymer (Onyx) Embolization Zachary L. Bercu, MD Department of Interventional Radiology, Icahn School."— Presentation transcript:
Transradial Type I Endoleak Ethylene Vinyl Alcohol Copolymer (Onyx) Embolization Zachary L. Bercu, MD Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York. Financial disclosures: None. Acknowledgements: Aaron Fischman, MD
History CC: “Expanding aneurysm with suspicious post-operative CT” HPI: 70 y/o male status post abdominal aortic aneurysm (AAA) repair in 2007 admitted for expanding right lower extremity hematoma. During admission, patient underwent emergent proximal and distal endoleak repair with a “snorkel” procedure, stent graft extension, left hypogastric coil embolization and placement of a left common iliac graft. The results of post-operative CT angiography led to interventional radiology referral.
History Relevant past medical and surgical history: Essential hypertension, hypercholesteremia, history of abdominal aortic aneurysm status post endovascular repair (EVAR) (2007), chronic obstructive pulmonary disease, history of myocardial infarction, coronary artery disease status post coronary stent placement x 3, depression Medications: Hydrochlorothiazide, oxycodone-acetaminophen, heparin, amlodipin, lisinopril, docusate sodium, sennosides, setraline, diphenhydramine, ondansetron Allergies: Naproxen: reaction unknown Physical exam: BP: 116/62 P: 75 T: 36.4 °C RR: 19. No acute distress. No wheezing. Abdomen non- tender. Extensive bilateral lower extremity and scrotal edema. Relevant labs: INR1.1 PT14.4 PTT
Original Endoleak Repair
Diagnosis and Panel Discussion Diagnosis: Persistent endoleak (type I?) Panel discussion: Options include: – Open surgical repair? Patient not a great candidate (multiple comorbidities). – Conventional endovascular repair? Complex anatomy (left external iliac occluded), most recent attempt unsuccessful, “snorkel” already performed. – Fenestrated endovascular graft? Not approved for use in the U.S. – Transradial endovascular repair? Which embolic agents to use? Coils vs. Glue? Onyx? Potential complications in general: embolization failure, non-target embolization, paralysis, “closing off” future access/options Onyx limitations: high radio-opacity (catheter tip obscuration), time consuming, expensive, inability to follow on CT 1
Figures 1 and 2 (cine). Digital subtraction angiography frontal full field-of-view and magnification projections demonstrate a type IA endoleak. Figure 3 (static). Frontal magnification view demonstrates a type IA endoleak at the proximal edge of the stent graft at the right renal stent snorkel.
Figures 3, 4 and 5 (static). An angled Glidewire was used to access the aneurysm sac, after which a total of 4 vials of Onyx and 23 Interlock coils were used before the endoleak ceased filling. An Amplatzer 4 plug was placed at the proximal entry site of the endoleak to complete the seal.
Figure 6 (static). Static image from contrast angiography demonstrates no filling of the aneurysm sac. Figure 7 (cine). Oblique projection completion angiogram again confirms absence of filling of the aneurysm sac. The coil/Onyx mass is highly radio-opaque.
Summary Follow-up: Patient discharged 3 days post-op without perioperative complication. Patient followed with MRA. Transradial approach well-known in cardiology literature. Common transradial procedures at our institution include: TACE, MAA prior to Y-90, UFE, GI bleed embolizations. Previous studies of Onyx for type 1 endoleaks: – 6 patients, 2 complications: 1 had renal artery graft and leg extension occlusions (thought to be unrelated to Onyx) and the other had late stentgraft migration of Onyx with aneurysm rupture 18 months post-op. 2 – 6 patients, no recurrent endoleaks. 1 Conclusion: Transradial Onyx embolization of a Type 1 endoleak may be performed successfully when other options are not available to patients. References: 1. Chun JY, Morgan R. Transcatheter embolisation of type 1 endoleaks after endovascular aortic aneurysm repair with Onyx: when no other treatment option is feasible. Eur J of Vasc and Endovasc Surg 2013;45(2): Henrikson O, Roos H, Falkenberg M. Ethylene vinyl alcohol copolymer (Onyx) to seal type 1 endoleak. A new technique. Vascular 2011;19(2):77-81.