Optimization of Type II Endoleak Embolization Using Onlay Fusion, Needle Assist Guidance, and Intraoperative Assessment with Contrast-enhanced Ultrasound

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Effectiveness of type II endoleak (T2E) embolization is highly variable. The purpose of this study was to evaluate a protocol for T2E embolization using onlay fusion, needle assist guidance and intraoperative assessment with contrast-enhanced ultrasound (IO-CEUS). We reviewed the clinical data of 28 consecutive patients (89% male; mean age, 81 ± 11 years) treated for T2E using the standardized protocol from 2016 to 2019. Aneurysm sac embolization was performed using combination of 0.018-inch coils and ethylene vinyl alcohol copolymer (Onyx-18) via transarterial (Fig 1) or translumbar (Fig 2) approach. IO-CEUS was performed to determine resolution of T2E with additional embolization performed whenever needed. Technical success was defined by access to intended T2E nidus, successful delivery of embolic material, and absence of nontarget embolization. Clinical success was defined by technical success, absence or near complete resolution of T2E, and stabilization of aneurysm sac diameter on follow-up imaging. T2E embolization was indicated for significant aneurysm sac enlargement averaging 10 ± 7 mm at a mean follow-up of 50 ± 34 months from the index endovascular aortic repair (endovascular aneurysm repair [EVAR]) in 18 patients (64%) or fenestrated-branched EVAR in 10 patients (36%). Twelve patients (43%) had prior failed attempts to treat the T2E. Translumbar access was used in 23 patients (82%) and transarterial approach in 5 patients (18%), all of whom had patent inferior mesenteric arteries. T2E embolization was performed using Onyx-18 in 27 patients (96%) and coils in 25 patients (89%). Technical success was achieved in all patients. Completion IO-CEUS demonstrated complete T2E resolution in 20 patients (71%) and persistent, but reduced T2E in 8 patients (29%). There was no mortality. Nineteen patients (68%) were discharged to home on the same day. Mean length of hospital stay was 0.5 ± 0.7 days. After a mean follow-up of 19 ± 11 months, 23 patients (82%) had clinical success with aneurysm sac stabilization, with significantly higher rates among patients who had no T2E on completion IO-CEUS (95% vs 50%; P = .014). Of the five patients (18%) who had persistent aneurysm sac enlargement of 5 mm or more, two required additional T2E embolization procedures, both of whom had residual T2E on completion IO-CEUS. There were no aortic ruptures. A protocol using onlay fusion and needle assist guidance to facilitate aneurysm sac embolization and IO-CEUS assessment to document complete resolution of the T2E achieved clinical success in 82% of patients. Absence of residual T2E on completion IO-CEUS predicted higher rates of clinical success.Fig 2Type 2 endoleak (T2E)-treated with translumbar approach. We use on-lay fusion based on the most recent computed tomography angiography study and intraoperative cone beam computed tomography scan (A). The patient is positioned in lateral decubitus (B). A plan is created based on the preoperative CTA and needle assist track software is used to facilitate advancement of needle via translumbar access (C). Once embolization is completed, a contrast-enhanced ultrasound is performed to assess the area of embolization (D).View Large Image Figure ViewerDownload Hi-res image Download (PPT)