IP007. Simplified Translumbar Treatment of a Type II Endoleak Using CT Fusion in Hybrid Room

Abstract

A 74-year-old man underwent endovascular aneurysm repair (EVAR) of a 5.0-cm infrarenal abdominal aortic aneurysm (AAA) with a stent graft. Endoleaks were not detected at the time of the completion angiogram. Follow-up aortic duplex study obtained 1 month later showed the presence of a small type II endoleak arising from the inferior mesenteric artery (IMA). The endoleak persisted and increased in size, with a subsequent sac diameter increase 3 years after EVAR. A follow-up computed tomography angiogram (CTA) showed the presence of type II endoleak, with retrograde filling by the IMA and connection to a complex network of lumbar vessels. The AAA sac increased in size to 5.8 cm. Decision was made to proceed with treatment to obliterate this endoleak. We describe a novel approach in treating a persistent type II endoleak related to the IMA and the lumbar outflow vessels using a simplified translumbar approach. Using TrackVision software, we were able to delineate the track to the level of the endoleak. The software program allowed us to access the endoleak through a translumbar approach. A three-dimensional cone-beam CT scan without contrast injection was used to identify the location of the endograft to match the exact position of the endoleak noted on the previous CTA in the superimposed prone position. After the entry and target trajectories were identified using both of the fused data sets, the model and planned trajectories were then exported into the TrackVision software, creating a virtual needle track. A 20-cm long, 18-gauge Chiba needle was used to access the endoleak cavity. Using progress and bull’s eye views, we were able to track the needle into the endoleak. The endoleak was then visualized using contrast showing feeding of the endoleak through the IMA. This entire region was then coil embolized with a total of four 4-mm × 3-mm Tornado Embolization Coils followed by one 5-mm × 10-cm and two 10-mm × 15-cm Nester Embolization Coils. After coil embolization the IMA was not visualized. The patient was seen in follow-up 1 month following the procedure with complete obliteration of the endoleak and decrease in sac size to 5.3 cm. This simplified approach at treating complex endoleaks has allowed the procedure to be performed with minimal fluoroscopy and digital subtraction angiography imaging. In addition, the length of the procedure has become significantly shortened with the use of the virtual needle track.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)