Cardiovasc Intervent Radiol (2011) 34:S122–S125 DOI 10.1007/s00270-010-9809-y
CASE REPORT
Percutaneous Transosseous Embolization of Internal Iliac Artery Aneurysm Type II Endoleak: Report of Two Cases Joseph J. Gemmete • Mohammad Arabi Wojciech B. Cwikiel
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Received: 18 August 2009 / Accepted: 8 December 2009 / Published online: 5 February 2010 Ó Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010
Abstract This report describes two cases of successful treatment of an internal iliac artery aneurysm (IIAA) type II endoleak utilizing a percutaneous transosseous access that could not be treated using an endovascular or standard percutaneous approach. A direct percutaneous approach through bone was chosen to avoid vital structures and the surrounding bowel. The procedure was successful and required minimal fluoroscopy time compared with other treatment options. We believe this procedure is an alternative to some of the more complex and technically challenging means of treating this lesion.
needed to access the endoleak if standard endovascular techniques fail [2]. We present two cases of percutaneous transosseous access into IIAA type II endoleak, which could not be treated through an endovascular or standard percutaneous approach. To our knowledge this is the first such description of treatment of an IIAA type II endoleak using a transosseous approach.
Case Reports Case No. 1
Keywords Internal iliac artery aneurysm Stent-graft Type II endoleak Treatment
Introduction Endoleak is defined as persistent perfusion of the aneurysmal sac after endovascular aneurysm repair. The significance of type II endoleak is as yet uncertain. However, it is generally agreed that when such a leak is accompanied by aneurysm expansion, appropriate intervention should be considered. Generally, type II endoleak is treated by way of endovascular access into the arterial branches supplying the endoleak [1]. A direct percutaneous approach may be J. J. Gemmete M. Arabi W. B. Cwikiel Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA J. J. Gemmete (&) Division of Vascular/Interventional Radiology, Department of Radiology, University of Michigan, 1500 E Medical Center Drive, UH B1 D328, Ann Arbor, MI 48109-5030, USA e-mail:
[email protected]
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A 78-year-old man was treated for a 6 9 4.5-cm right internal iliac artery aneurysm (IIAA) that was causing compression of the right iliac vein and erosion of the sacrum. After initial coil embolization of the branches supplying the IIAA, overlapping AneuRx stent grafts (Medtronic, Santa Rosa, CA, USA) were placed from the aortic bifurcation into the external iliac artery (EIA). After stent graft placement, through a jailed catheter placed into the aneurysm, the residual IIAA was injected with Gelfoam and thrombin. Three overlapping 14 9 60-mm Wallstents (Boston Scientific, Natick, MA, USA) were deployed from the inferior vena cava (IVC) bifurcation into the external iliac vein because of the extrinsic compression caused by the aneurysm. Final angiogram and venogram showed exclusion of the right IIAA with widely patent arterial stent-grafts and venous stents (Fig. 1A). A computed tomography (CT) scan after 1 year demonstrated evidence of type II endoleak with enlargement of the IIAA from 6 to 7 cm. Based on these findings, a decision was made to treat the endoleak. Follow-up angiogram demonstrated filling of the type II endoleak from branches off the right L4 and L5 lumbar arteries along
J. J. Gemmete et al.: Percutaneous Transosseous Embolization of IIAA Type II Endoleak
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Fig. 1 Case no. 1. A Anteroposterior (AP) pelvic angiogram showing the AneuRx (Medtronic) stent graft (small arrow) in the right iliac artery and a Wallstent (Boston Scientific; large arrow) in the right iliac vein. B AP pelvic angiogram late-phase showing filling of the type II endoleak within the right IAA (arrow). C Oblique prone CT
scan showing projection of the needle through bone into the right IIAA (arrow). D Spot fluoroscope image showing contrast mixed with Gelfoam slurry and thrombin filling the aneurysm. E Axial contrast pelvic CT at 6-month follow-up showing a stable-size aneurysm with no filling of the endoleak (arrow)
with branches off the left IIA. The arterial feeders to the endoleak off the lumbar arteries were embolized with Trufill n-BCA glue (Codman Neurovascular, Raynham, MA, USA); however, final angiogram demonstrated persistent filling of the endoleak from multiple branches off the left IIA (Fig. 1B). Given the difficulty in trying to catheterize the left IIA branches, the fluoroscopy time of the procedure, and the patients increased creatinine level, a direct percutaneous approach into the aneurysm was chosen to exclude the type II endoleak. A transosseous pelvic route was chosen as a shortest, safest route into the aneurysm that would avoid loops of bowel. The patient was placed prone, with his right side elevated, on the CT scanner. After administering intravenous conscious sedation and local anesthesia, an 11-gauge vertebroplasty needle was advanced under CT guidance through the right iliac bone. Through this needle, a 19 gauge 9 20-cm length Chiba needle was placed coaxially into the right IIAA (Fig. 1C). Back-bleeding from the needle was noted immediately after its insertion into the aneurysm. 20 ml of contrast mixed with a Gelfoam slurry
and 5000 U thrombin was injected into the aneurysm under fluoroscopy (Fig. 1D). There were no immediate complications related to the procedure, and the patient was discharged from the hospital after a 24-h admission. Followup CT scan at 6 months demonstrated no evidence of a type II endoleak and a stable aneurysm 6 cm in size (Fig. 1E). Case No. 2 A 56-year-old man was treated for a 6-cm distal left common iliac artery aneurysm (CIAA) extending into the left internal artery and the EIA approximately 8 cm cranial from the takeoff of a left renal transplant artery. In addition, a 2-cm right CIAA and a 3.5-cm IIAA were present. The left IIAA was initially embolized with coils proximal to the anterior and posterior division. A bifurcated AneuRx stent graft system (Medtronic) was deployed from just below the native renal arteries into both EIAs. Given that there was no normal landing zone in the distal right CIA, the stent graft on the right side was placed into the EIA.
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J. J. Gemmete et al.: Percutaneous Transosseous Embolization of IIAA Type II Endoleak
Fig. 2 Case no. 2. A Axial contrast pelvic CT showing filling of type II endoleak within the left IIAA (arrow). B Prone pelvic CT scan showing projection of the needle through the bone into the left IIAA (arrow). C Spot fluoroscopic image (patient prone) showing filling of the left IIAA with a Bentson wire (Cook; large arrow), Trufill n-BCA glue (Codman Neurovascular; arrow head), and coils (small arrow). D Axial contrast pelvic CT at 3-month follow-up showing a stable aneurysm with no filling of the endoleak. Coils can be seen in the aneurysm (arrow)
A CT scan after 1 year demonstrated evidence of a type II endoleak involving the left IIAA and continued eccentric growth of the aneurysm (Fig. 2A). After an unsuccessful attempt to embolize the aneurysm using endovascular approach from the left femoral artery, a percutaneous transosseous access was used. The patient was placed prone on the CT scanner. After administering intravenous conscious sedation and local anesthesia and making a posterior lateral approach, an 11-gauge bone-biopsy needle was advanced through the left iliac bone (Fig. 2B). Coaxially through this needle, a 20 gauge 9 20-cm Chiba needle was advanced into the aneurysm. Minimal back-bleeding was noted from the needle. The patient was then transferred to the angiography suite. Under fluoroscopic guidance, a V-18 wire (Boston Scientific, Natick, MA, USA) was advanced through the needle into the aneurysm. The needle was removed, and a 5F Kumpe catheter (Cook, Bloomington, IN, USA) was placed into the aneurysm. The aneurysm was coiled with two (15 mm 9 8 cm) Gianturco coils and five (10 mm 9 4 cm) Tornado coils (Cook, Bloomington, IN, USA). The sac was then further embolized with a 20 cmlong spiral part of a 0.035 in. Bentson wire (Cook,
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Bloomington, IN, USA). Finally, a high-flow renegade microcatheter (Boston Scientific, Natick, MA, USA) was advanced coaxially through the Kumpe catheter into the aneurysm, and the residual sac was embolized with 5 cc of a 2:1 mixture of ethiodol to Trufill n-BCA glue (Codman Neurovascular) (Fig. 2C). Three-month and 1 year followup CT scans showed shrinking aneurysm size (\6 cm) and no endoleak (Fig. 2D).
Discussion An endoleak is detected when there is abnormal blood flow outside the graft prosthesis but within the aneurysm sac. This may maintain arterial pressure within the aneurysm sac and prevent contraction, or it may cause expansion. Endoleak occurring after endograft treatment of aneurysm is classified into five types based on the site of leakage [3]. Type I endoleak occurs at the proximal or distal landing zones of the graft. Type II endoleak occurs secondary to collateral flow into the aneurysm from branch vessels, such as the mesenteric or lumbar arteries. Type III endoleak occurs between the modular components of the endograft
J. J. Gemmete et al.: Percutaneous Transosseous Embolization of IIAA Type II Endoleak
or through tears or defects in the graft itself. Type IV endoleak occurs through pores in the graft fabric. Type V endoleak is defined as an increase in maximum aneurysm diameter without detectable endoleak [4]. Although type II and IV endoleaks are often self-limited and resolve spontaneously, types I and III are potentially dangerous and require immediate intervention to repair [3]. Type V endoleaks that are left untreated may lead to continuous enlargement and consecutive rupture of the aneurysmal sac, although there are very few reports of this in the literature [4]. Although most experts in the field consider type II endoleaks to have a benign course [1, 5], in some cases they assume clinical significance when those perigraft channels remain open after 6 months or appear de novo, during patient follow-up, resulting in aneurysmal sac expansion. Aneurysmal growth could possibly dilate the proximal neck and the distal landing zones, thus promoting migration or disconnection of the components of the endograft by changing the morphology of the aneurysm. Decision to treat type II endoleak is generally based on persistent flow in the aneurysmal sac with interval expansion of the aneurysm. Recent studies investigated the value of intra-aneurysmal pressure-monitoring devices, which may enforce the decision to treat in the setting of type II endoleak [6, 7]. When the decision is made to treat type II endoleak, the options include conversion to open procedure, endovascular treatment with or without direct percutaneous approach, and laparoscopic or video-assisted minilaparotomy with clipping of lumbar and/or inferior mesenteric arteries [2, 8, 9]. Failure of endovascular treatment of type II endoleak may be secondary to persistent flow through the coils in the treated vessel, development of a retiform anastomosis around the coiled vessel, and development of a new endoleak after successful occlusion of a diagnosed endoleak [10]. The previously listed options are mainly for type II endoleak involving abdominal aortic aneurysm. Few series have described how to treat type II endoleak involving IIAA. In our cases, the endovascular options failed, and the type II endoleak was treated using a transosseous approach
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to avoid vital structures, mainly loops of bowel. Possible complications from a transosseous approach include osteomyelitis, retroperitoneal hemorrhage, and possible fracture of the bone being transgressed. The investigators do not routinely administer antibiotics in cases like this unless there is a breach in sterile technique. The two IIAA type II endoleaks were successfully treated using a transosseous approach without complications and with good midterm results.
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