Type II Endoleaks: When and Howto TreatDr Simon NeequayeAdvanced Endovascular Surgery FellowMcGill University and Jewish G...
Plan• Review the incidence and clinical significance oftype 2 endoleaks• Review treatment options and results of suchthera...
‘persistent blood flow outside the graft andwithin the aneurysm sac.’
signficance of Endoleaks• 60 % of complications after EVAR• 45 % of all re-interventions• Type 2 Endoleak more common than...
Are we failing to adequately treat somepatients?
Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate fa...
Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate fa...
Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate fa...
Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate fa...
Type 1 Type 3• High Pressure Endoleaks present an obviousproblem.
Type 2
• Type 2 Endoleak on post operative CTA 1 in 3 patients(at least 1 month post op)1: El Batti S, Cochennec F, Roudot-Thorav...
1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aorti...
1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aorti...
1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aorti...
1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aorti...
• Pre-operative embolisation of lumbars or IMA had no effect onincidence of T2E (23 patients)• No difference in presence o...
• Recurrent as well as Persistent Type 2 endoleakleads to aneurysm sac enlargement and life-threatening complications.• Th...
Post EVAR imaging is mandatory
• Surveillance tests★ Duplex★ CTA★ Plain XrayPost EVAR imagingMonitor sac size and device integrity
• Special tests-★ Contrast enhanced Ultrasound★ MRI★ Catheter AngiographyPost EVAR imagingDelineate source of endoleak
Colour Duplex scan of patient with sac enlargement from 7cm to7.5 cm
Colour Duplex scan of patient with sac enlargement from 7cm to7.5 cm
Treatment of Type 2 Endoleak• Occlude Feeding vessels★Trans-arterial embolisation★Surgical ligation of feeding vessels (Op...
Trans-Arterial embolisation of IMA via SMA
Trans-Arterial embolisation of IMA via SMA
Trans-Arterial embolisation of IMA via SMA
Trans-Arterial embolisation of IMA via SMA
Trans-arterial via Ilio-lumbarroute
Direct Aneurysm puncture• Trans peritoneal★ 22-gauge Chiba needle★ USS guided• Trans Lumbar★ Fluoroscopic or CT guidance
Embolisation agents• Detachable coils• Cyanoacrylate glue• Thrombin• Onyx
• 60 % require multiple procedures• Isolated IMA source of embolisation results in 72 % freedomfrom re-intervention at 2 y...
Onyx glue embolization was associated with a greater success rate whenused as the initial secondary intervention(odds rati...
Onyx glue embolization was associated with a greater success rate whenused as the initial secondary intervention(odds rati...
Approximately 50 x priceof goldOnyx glue embolization was associated with a greater success rate whenused as the initial s...
• Aggressive laparascopic approach with clipping ofall branches followed by evacuation of sac andoversewing of remaining b...
1: Phade SV, Keldahl ML, Morasch MD, Rodriguez HE, Pearce WH, Kibbe MR, EskandariMK. Late abdominal aortic endograft expla...
Other approaches
Conclusion:1)We Know Type 2 Endoleaks can cause sac expansion.2)We Think we should treat some of them•Sac expansion >5mm•P...
QuickTime™ and adecompressorare needed to see this picture.
Thank you.
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
2013session6 2
Upcoming SlideShare
Loading in …5
×

2013session6 2

443 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
443
On SlideShare
0
From Embeds
0
Number of Embeds
23
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

2013session6 2

  1. 1. Type II Endoleaks: When and Howto TreatDr Simon NeequayeAdvanced Endovascular Surgery FellowMcGill University and Jewish General Hospital
  2. 2. Plan• Review the incidence and clinical significance oftype 2 endoleaks• Review treatment options and results of suchtherapies
  3. 3. ‘persistent blood flow outside the graft andwithin the aneurysm sac.’
  4. 4. signficance of Endoleaks• 60 % of complications after EVAR• 45 % of all re-interventions• Type 2 Endoleak more common than all other types ofendoleak combinedEVAR trial participants. Endovascular aneurysm repair versus open repairinpatients with abdominal aortic aneurysm (EVAR trial 1): randomisedcontrolled trial. Lancet. 2005 Jun 25-Jul 1;365(9478):2179-86.
  5. 5. Are we failing to adequately treat somepatients?
  6. 6. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur JVasc Endovasc Surg. 2009 Jan;37(1):15-22. doi: 10.1016/j.ejvs.2008.10.011.Epub 2008 Nov 12.• Endoleaks were describedas the main cause ofrupture in 160 of 235(70 %)of patients with rupturedAAA following infra-renalEVAR.
  7. 7. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur JVasc Endovasc Surg. 2009 Jan;37(1):15-22. doi: 10.1016/j.ejvs.2008.10.011.Epub 2008 Nov 12.• Endoleaks were describedas the main cause ofrupture in 160 of 235(70 %)of patients with rupturedAAA following infra-renalEVAR.
  8. 8. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur JVasc Endovasc Surg. 2009 Jan;37(1):15-22. doi: 10.1016/j.ejvs.2008.10.011.Epub 2008 Nov 12.• Endoleaks were describedas the main cause ofrupture in 160 of 235(70 %)of patients with rupturedAAA following infra-renalEVAR.
  9. 9. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur JVasc Endovasc Surg. 2009 Jan;37(1):15-22. doi: 10.1016/j.ejvs.2008.10.011.Epub 2008 Nov 12.• Endoleaks were describedas the main cause ofrupture in 160 of 235(70 %)of patients with rupturedAAA following infra-renalEVAR.
  10. 10. Type 1 Type 3• High Pressure Endoleaks present an obviousproblem.
  11. 11. Type 2
  12. 12. • Type 2 Endoleak on post operative CTA 1 in 3 patients(at least 1 month post op)1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aortic aneurysm are not always a benigncondition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.Epub 2013 Mar 7.
  13. 13. 1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aortic aneurysm are not always a benigncondition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.Epub 2013 Mar 7.
  14. 14. 1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aortic aneurysm are not always a benigncondition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.Epub 2013 Mar 7.
  15. 15. 1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aortic aneurysm are not always a benigncondition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.Epub 2013 Mar 7.
  16. 16. 1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aortic aneurysm are not always a benigncondition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.Epub 2013 Mar 7.
  17. 17. • Pre-operative embolisation of lumbars or IMA had no effect onincidence of T2E (23 patients)• No difference in presence of type I or Type III endoleakbetween the two groups ( T2E 24 % vs no T2E 27% p=0.8)1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aortic aneurysm are not always a benigncondition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.Epub 2013 Mar 7.
  18. 18. • Recurrent as well as Persistent Type 2 endoleakleads to aneurysm sac enlargement and life-threatening complications.• These should be closely monitored to ensure earlyand specific treatment.1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaksafter endovascular repair of abdominal aortic aneurysm are not always a benigncondition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.Epub 2013 Mar 7.
  19. 19. Post EVAR imaging is mandatory
  20. 20. • Surveillance tests★ Duplex★ CTA★ Plain XrayPost EVAR imagingMonitor sac size and device integrity
  21. 21. • Special tests-★ Contrast enhanced Ultrasound★ MRI★ Catheter AngiographyPost EVAR imagingDelineate source of endoleak
  22. 22. Colour Duplex scan of patient with sac enlargement from 7cm to7.5 cm
  23. 23. Colour Duplex scan of patient with sac enlargement from 7cm to7.5 cm
  24. 24. Treatment of Type 2 Endoleak• Occlude Feeding vessels★Trans-arterial embolisation★Surgical ligation of feeding vessels (Open or Laparoscopic)• Induction of Sac Thrombosis• Open conversion.
  25. 25. Trans-Arterial embolisation of IMA via SMA
  26. 26. Trans-Arterial embolisation of IMA via SMA
  27. 27. Trans-Arterial embolisation of IMA via SMA
  28. 28. Trans-Arterial embolisation of IMA via SMA
  29. 29. Trans-arterial via Ilio-lumbarroute
  30. 30. Direct Aneurysm puncture• Trans peritoneal★ 22-gauge Chiba needle★ USS guided• Trans Lumbar★ Fluoroscopic or CT guidance
  31. 31. Embolisation agents• Detachable coils• Cyanoacrylate glue• Thrombin• Onyx
  32. 32. • 60 % require multiple procedures• Isolated IMA source of embolisation results in 72 % freedomfrom re-intervention at 2 years• Success of initial intervention for lumbar endoleak was 17 %,with a 40 % success following secondary interventions.Gallagher KA, Ravin RA, Meltzer AJ, Khan MA, Coleman DM, Graham AR, AielloF,Shrikhande G, Connolly PH, Dayal R, Karwowski JK. Midterm outcomes aftertreatment of type II endoleaks associated with aneurysm sac expansion. JEndovasc Ther. 2012 Apr;19(2):182-92.Results of Trans arterialembolisation
  33. 33. Onyx glue embolization was associated with a greater success rate whenused as the initial secondary intervention(odds ratio, 59.61; 95% confidence interval, 4.78-742.73; P < .001).
  34. 34. Onyx glue embolization was associated with a greater success rate whenused as the initial secondary intervention(odds ratio, 59.61; 95% confidence interval, 4.78-742.73; P < .001).2
  35. 35. Approximately 50 x priceof goldOnyx glue embolization was associated with a greater success rate whenused as the initial secondary intervention(odds ratio, 59.61; 95% confidence interval, 4.78-742.73; P < .001).2
  36. 36. • Aggressive laparascopic approach with clipping ofall branches followed by evacuation of sac andoversewing of remaining branches.• 60 % sac growth at 6 years followup.
  37. 37. 1: Phade SV, Keldahl ML, Morasch MD, Rodriguez HE, Pearce WH, Kibbe MR, EskandariMK. Late abdominal aortic endograft explants: indications and outcomes. Surgery.2011 Oct;150(4):788-95.2: Marone EM, Mascia D, Coppi G, Tshomba Y, Bertoglio L, Kahlberg A, Chiesa R.Delayed Open Conversion after Endovascular Abdominal Aortic Aneurysm:Device-specific Surgical Approach. Eur J Vasc Endo3:Forbes TL, Harrington DM, Harris JR, DeRose G. Late conversion of endovascularto open repair of abdominal aortic aneurysms. Can J Surg. 2012 Aug;55(4):254-8.• Supraceliac control usually required• Mortality 2-13 %• Morbidity 30 %Open conversion
  38. 38. Other approaches
  39. 39. Conclusion:1)We Know Type 2 Endoleaks can cause sac expansion.2)We Think we should treat some of them•Sac expansion >5mm•Persistent Type 2 Endoleak??3)Our current Embolisation techniques are Probably noteffective in the long term management of Type 2 Endoleaks.
  40. 40. QuickTime™ and adecompressorare needed to see this picture.
  41. 41. Thank you.

×