Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Transradial Type I Endoleak Ethylene Vinyl Alcohol Copolymer (Onyx) Embolization Zachary L. Bercu, MD Acknowledgements: Aaron Fischman, MD Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York. E-mail: [email protected]. Financial disclosures: None. 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 nontender. Extensive bilateral lower extremity and scrotal edema. • Relevant labs: 9.1 11.3 27.8 137 133 94 15 3.7 27 1.1 100 INR 1.1 PT 14.4 PTT 38.4 Original Endoleak Repair CTA 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 CT1 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): 141-4. 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.