Value of Preliminary Selective Lumbar and Inferior Mesenteric Artery Embolization to Prevent Type II Endoleaks After Endovascular Aneurysm Repair

Abstract

Preliminary selective lumbar artery (LA) and inferior mesenteric artery (IMA) embolization to prevent type II endoleaks (T2ELs) has not been widely evaluated. Our aim was to determine the rate of endoleak and size decrease of infrarenal abdominal aortic aneurysm after endovascular aneurysm repair (EVAR) after pre-emptive coil embolization of IMA and LA in patients at high risk for T2EL. Between September 2014 and September 2019, 139 of 244 patients (56.9%) who underwent EVAR for abdominal aortic aneurysm also underwent selective percutaneous embolization of the IMA and LA before or during EVAR because of risk factors for T2EL. The embolization was performed using either coils or vascular plugs to achieve occlusion of the target vessel confirmed on angiography. Computed tomography and contrast-enhanced ultrasound imaging were performed at 1 month and 6 months and yearly after the procedure to detect endoleaks and to assess the aneurysm sac diameter. Mean follow-up was 23 ± 16 months (range, 1-61 months). Patients had a median of five (range, one to eight) patent LAs and IMAs on preoperative imaging. After completion of embolization, 80% (range, 20%-100%) of direct arterial flow to the aneurysm sack was occluded, with no procedurally related complications. Follow-up imaging showed T2EL in seven patients (5 %). Increase of the aneurysm sac was seen in eight patients during follow-up, of whom two had type I endoleak and six had T2EL. Six T2EL-related interventions were performed during follow-up, of which only one was successful. Shrinkage of the aneurysm sac diameter was in mean 9.2 ± 7.7 mm, which was statistically significant (P < .001). Surgery was required in one patient for proximal type I endoleak. No aneurysm-related death occurred. Preliminary selective LA and IMA embolization for patients at risk for T2EL is safe and effective in preventing development of T2EL. This procedure is associated with rapid decrease in aneurysm sack size.