CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate...

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CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical University of South Carolina Charleston, SC

Transcript of CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate...

Page 1: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

CANNES 2004

Endoleaks : graft extensionor coil embolization ?

Claudio Schönholz,MD Associate Professor of Radiology

Heart and Vascular Center Medical University of South Carolina

Charleston, SC

Page 2: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Endoleak

White GH, May J, Waugh RC, Chaufour X, Yu W. Type III and type IV endoleak: toward a complete definition of blood flow in the sac after endoluminal AAA repair. J Endovasc Surg 1998;5:305309.

“Presence of flow at the aneurysmal sac after stent-graft

treatment”

Page 3: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

• Type I endoleak

- Proximal or distal attachment

• Type II endoleak

- Retrograde branch flow

• Type III endoleak

- Structural defect or component junction

• Type IV endoleak

- Trans-graft leakage or porosity

Endoleak Types

Page 4: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Prevention of Type I Endoleak

• Case Selection

• 20 % oversizing of the endograft.

• Generous overlapping of segments.

• Graft covers the aorta and common iliac arteries from the renal arteries down to the iliac artery bifurcation.

Page 5: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Possible reasons of having low incidence of Type I endoleaks:

• No procedure was considered finished until complete sealing of the endograft was obtained.

• Sealing of the ends and connections was achieved by applying balloon dilatation, cuffs and malleable stents at the ends ( Extra-large Palmaz)

PARODI, JC

Page 6: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Type I Endoleak

Page 7: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Type I Endoleak

Page 8: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Prevention of Type II Endoleak:IMA Embolization

Page 9: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Prevention of Type II Endoleak: Lumbar Artery Embolization

Page 10: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Prevention of Type II Endoleak: Lumbar Artery Embolization

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WHEN SHOULD TYPE II ENDOLEAKS BE TREATED?

“If the endoleak continues to be present on the 6-

month scan, there is a small chance that it will spontaneously thrombose”

• Treat a type II endoleak if there is evidence of sac enlargement

• Intervene if a type II endoleak is present on the 6-month scan regardless of the status of an aneurysm sac

6-month CT scan

Page 12: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

ENDOLEAK ANATOMY

• Simple: small cavity and has ingress and egress from a single vessel

• Complex: multiple ingress and egress vessels

Page 13: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

• Blood enters during systole into the endoleak cavity, swirling around, leaving the endoleak cavity during diastole

• Physiology similar to a pseudo-aneurysm• May spontaneously

thrombose prior to the 6-month CT scan

ENDOLEAK ANATOMY“Simple”

Page 14: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

ENDOLEAK ANATOMY“Complex”

• Multiple ingress and egress vessels

• Behave like arteriovenous malformations

• Persists longer than 6 months.

Page 15: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

How to treat Type II Endoleaks:Embolize the artery feeding the endoleak

cavity by a transarterial route ?

• This technique has proved ineffective, providing only short-term response if the sac can not be reached by the embolic agent.

• Endoleaks will recur by recruiting additional aortic branch vessels.

Page 16: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

The endoleak cavity acts as an “Arteriovenous malformation nidus,” and thrombosing this nidus is what provides a successful and durable response.

Richard A. Baum, MDDo stable type II endoleaks require treatment after EVAREndovascular Today

Page 17: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Type II Endoleak:Embolization with Glue

Page 18: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

TYPE II ENDOLEAK FROM IMA

•67 Years old High Risk Patient.

•6.5 cm AAA treated 14 month ago with Gore Excluder Device.

•CT scan showed Type II Endoleak from IMA and the AAA remain same size.

•Indication:Endovascular Embolization

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Page 21: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.
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How to treat Type II Endoleaks:translumbar needle stick ?

• Coils and glue to completely thrombose the endoleak cavity

• Instead of treating feeding vessels, the endoleaks themselves are being embolized

• The connection between ingress and egress vessels, as well as the endoleak cavity, is destroyed

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Type II Endoleak

Page 24: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

6 Months FUGelfoam-ThrombinTranslumbar

Translumbar Embolization

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Translumbar Embolization of Type 2 Endoleaks after Endovascular Repair of

Abdominal Aortic Aneurysms

• 7 Patients with Type 2 Endoleak

• 4 lumbar, 3 IMA

• 19-gauge,20cm needle w/5fr.Teflon Sheath

• Gianturco Coils (CooK)

• 100% Initial Success

• No Complications

R.A.Baum;C.Cope; R.Fairaman;J.CarpenterJ.Vasc Interv Radiol 2001;12:111-116

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Type III Endoleak

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Type III Endoleak

Page 28: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Type III Endoleak

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Management of Endoleaks

• Type I: Immediate treatment. Balloon,Cuff, Palmaz or Conversion to Open Procedure.

• Sealed Type I: If large Treat ,If small Watch. If size does not decrease Treat.

• Type II: Treat after 6 months if aneurysmal size do not decrease.

• Late Type I or III: Treat immediately.

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Obliteration of the Aneurysmal Sac in Abdominal Aortic

Aneurysms in an Animal Model

Renan Uflacker,MD

Page 31: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Pig #3AAA creation

Volume measurement15 cc’s

Post TreatmentEndoleak

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24 Week FUPig # 3

Page 33: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Results

• The treatment of the AAA was technically successful in all animals with total exclusion of the sac

• The AAA sac acquired a firm rubberish consistency after treatment

• Fibrosis and calcifications were detected within the sac, mostly around the graft and in contact with the aortic wall after 4 to 6 weeks.

• There was inflammatory reaction to the Dacron material and to the polymer (to a lesser extent)

• Significant adhesion of the AAA with surrounding structures was observed

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Results

• After 4 to 6 weeks there is a tendency for shrinkage of the AAA sac, apparently maximized by the 24th week

• There was no sac recanalization in the follow up time ranging from 1 to 24 weeks

• The controls at 6 and 12 weeks showed shrinkage of the AAA sac (histology not ready yet)

Page 35: CANNES 2004 Endoleaks : graft extension or coil embolization ? Claudio Schönholz,MD Associate Professor of Radiology Heart and Vascular Center Medical.

Conclusions

• pGlcNAc Glucosamine in the gel form is an unique hemostatic material

• Promotes rapid clotting within the AAA sac• Also effective under systemic anticoagulation• Effective aneurysm sac filling with occlusion of branches as necessary • Easy to use and cost effective• It seems to have gradual longer term absorption allowing

AAA shrinkage over a period of 24 weeks but not before 6 weeks

• Experience is necessary for volumetric measurement• A human trial is warranted