J ENDOVASC THER 2005;12:579–582- Tecnical Note-Fibrin Glue Aneurysm Sac Embolization at the Time of Endografting (Chirurgia Vascolare-ULSS 15 Alta Padovana) (Vascular Surgery -ULSS 15 Alta Padovana)

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ᮊ 2005 by the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS Available at www.jevt.org
ࡗTECHNICAL NOTE ࡗ
Fibrin Glue Aneurysm Sac Embolization
at the Time of Endografting
Mario Zanchetta, MD, FSCAI; Francesca Faresin, MD; Luigi Pedon, MD;
Melania Riggi, MD; and Salvatore Ronsivalle, MD
Department of Cardiovascular Disease, Cittadella, Padua, Italy.
ࡗ ࡗ
Purpose: To describe the procedural details for primary prevention of type II endoleak with
fibrin glue injection into the aneurysm sac at the time of endografting.
Technique: After deployment of the main stent-graft component, the angiographic pigtail
catheter is withdrawn, leaving the 0.035-inch standard guidewire between the endograft
and the native aorta. Through a brachial-femoral arterial guidewire loop, an 11-cm-long,
6-F introducer is advanced over the wire into the contralateral iliac artery. After deployment
of the contralateral iliac extension, a 23-cm, 5-F sheath is advanced over the wire into the
aneurysm sac. The wire and vessel dilator are removed, leaving the cannula in the sac. To
prevent distal embolization of the sealant, a balloon is inflated in the contralateral limb to
secure it to the native vessel before 5 mL of fibrin sealant are injected into the sac via a
double-syringe delivery system inserted through the sheath. The balloon is left in place
for 1 minute after sealant injection. In 64 consecutive patients in whom this technique has
been used, sac embolization has been successful. There have been no intraoperative com-
plications or in-hospital mortality. Over a mean follow-up of 9.3Ϯ4.4 months (range 1–18),
only 1 lumbar endoleak has been detected on surveillance imaging.
Conclusions: This preventive strategy appears to be an effective approach and the best
therapeutic choice for preventive management of type II endoleak.
J Endovasc Ther 2005;12:579–582
Key words: abdominal aortic aneurysm, endovascular repair, stent-graft, type II endoleak,
fibrin glue, sac embolization
ࡗ ࡗ
The authors have no commercial, proprietary, or financial interest in any products or companies described in this article.
Address for correspondence and reprints: Mario Zanchetta, MD, FACA, FSCAI, FESC, Dipartimento di Malattie Cardio-
vascolari, Ospedale Civile, Via Riva Ospedale, 35013 Cittadella, Padova, Italy. Fax: 39-049-9424531; E-mail: emodinacit@
ulss15.pd.it
Persistent aneurysm perfusion after endovas-
cular abdominal aortic aneurysm (AAA) repair
(EVAR) has been reported in 14% to 29% of
patients in clinical trials.1,2 To avoid the risk of
aneurysm expansion or rupture resulting
from retrograde endoleak3,4 and the second-
ary interventions that are required in up to
10% of stent-graft patients per year,5 we have
used fibrin glue sac embolization at the time
of EVAR to primarily prevent type II endoleak.
TECHNIQUE
With approval of the hospital’s Ethics Com-
mittee and with patient informed consent, we
have been performing sac embolization dur-
ing elective AAA stent-graft repair since June
2003. The commercial fibrin glue (Tisseel/Tis-
sucol; Baxter/Hyland Immuno, Vienna, Aus-
tria), a solution of 3000 U/mL of aprotinin and
500 IU of thrombin, has been approved for
clinical use in Europe since 1976. Before the
endovascular procedure, all patients under-
went contrast-enhanced computed tomogra-
phy and digital subtraction angiography to
delineate aneurysm morphology and to ana-
lyze lumbar (LA) and inferior mesenteric ar-
tery (IMA) patency.
The procedures were performed under a

2. 580 PRIMARY PREVENTION OF TYPE II ENDOLEAK
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Figureࡗ(A) Intraoperative angiogram showing the Talent delivery system (DS) and a 0.035-
inch standard guidewire (GW) between the endograft and the native aorta. (B) Radiopaque
tip (dotted circle) of a 23-mm-long, 5-F introducer within the aneurysm sac. (C) Selective
visualization of the aneurysm sac showing patent lumbar (LA) and inferior mesenteric arteries
(IMA). (D) Successful fibrin glue sac embolization, resulting in LA and IMA occlusion.
uniform protocol by creating a brachial-fem-
oral artery access. For the purposes of this de-
scription, the primary side for insertion of the
bifurcated graft was the right femoral artery.
Initially, a calibrated 5-F angiographic pigtail
catheter (Super Torque MB; Cordis Europa,
Roden, The Netherlands) was inserted
through the left common femoral artery over
a 0.035-inch standard guidewire (Emerald;
Cordis) for angiography. After deploying the
main stent-graft component with its iliac limb,
the pigtail catheter was withdrawn, leaving
the guidewire in place between the endograft
and the native aorta (Figure, A). Through the
left brachial-right femoral arterial guidewire
loop, an 11-cm-long, 6-F introducer (Advent;
Cordis) was advanced over the wire into the
right iliac artery, and angiography was per-
formed to verify proper distal sealing to avoid
subsequent distal sealant embolization.
After deployment of the contralateral iliac
extension, a 23-cm, 5-F Brite Tip sheath with

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a radiopaque tip (Cordis) was advanced under
fluoroscopic guidance (Figure, B) over the
0.035-inch guidewire into the aneurysm sac.
Subsequently, the wire and the Brite Tip’s ves-
sel dilator were removed, leaving the cannula
in the aneurysm sac. An aneurysmogram was
performed (Figure, C). A 25-cm-long, double-
lumen Duplocath catheter mounted on a Y-
connector Duploject (Baxter/Hyland Immuno)
was inserted into the Brite Tip sheath. To pre-
vent distal embolization of the sealant, a bal-
loon was inflated in the left stent-graft limb to
secure it to the native vessel before injecting
5 mL of fibrin sealant into the sac via the 2
syringes in the Duploject. The balloon was left
in place for 1 minute after sealant injection.
Finally, the aneurysmogram was repeated to
verify sac embolization and aortic side branch
occlusion (Figure, D).
We have used this approach in 64 consec-
utive patients (60 men; mean age 74.3Ϯ7.0
years, range 64–86) with degenerative AAA
undergoing elective EVAR up to December
2004. The mean sac and proximal neck di-
ameters were 48Ϯ12 and 23.5Ϯ3.7 mm, re-
spectively; the mean neck length was 22Ϯ11
mm. The majority of patent aortic side
branches were LAs, ranging from 1 to 3
paired vessels per patient, whereas only 10
patent IMAs were detected in the preopera-
tive imaging studies. Catheterization of the
sac and thrombin glue injection immediately
after stent-graft deployment (58 Talent and 8
AneuRx [Medtronic Vascular, Santa Rosa, CA,
USA]) was carried out successfully in all cas-
es. There were no intraoperative complica-
tions or in-hospital mortality. Over a mean fol-
low-up of 9.3Ϯ4.4 months (range 1–18), only
1 LA endoleak was detected on surveillance
CT.
DISCUSSION
Injection of fibrin glue into an aneurysm sac
during endografting appears feasible and, ac-
cording to our experience, may decrease type
II endoleaks and the need for repeated inter-
ventions. We believe that only one injection
of fibrin glue may be necessary for sac em-
bolization at the time of EVAR, offering certain
advantages over other current methods6–9 for
the prevention/treatment of type II endoleaks.
Firstly, precise delivery of fibrin glue is easy
to achieve independent of the type of endo-
graft (i.e., transrenal or suprarenal fixation) or
tortuous iliac arteries because access to the
aneurysm sac is obtained by leaving the
guidewire between the endograft and the na-
tive aorta when the pigtail catheter is with-
drawn. Secondly, primary aneurysm sac em-
bolization at the time of endografting might
avoid much more challenging preventive6,7 or
secondary8,9 interventions. Thirdly, unlike the
prophylactic thrombogenic sponge proce-
dure,6 the fibrin glue sac embolization tech-
nique appears to be the best anatomical re-
construction approach. While this method can
be successful for aortic side branch occlusion,
we do not advocate it for prevention of type I
endoleaks.
Conclusions
This preventive ‘‘ad hoc’’ strategy provides
easier aortic side branch occlusion than trans-
arterial and translumbar embolotherapy, and
the results are an improvement compared
with historical data.10 However, these prom-
ising early experiences must be corroborated
by longer follow-up.
REFERENCES
1. Zarins CK, White RA, Schwarten D, et al.
AneuRx stent graft versus open surgical repair
of abdominal aortic aneurysms: multicenter
prospective clinical trial. J Vasc Surg. 1999;29:
292–308.
2. Faries PL, Brener BJ, Connelly TL, et al. A mul-
ticenter experience with the Talent endovas-
cular graft for the treatment of abdominal aor-
tic aneurysms. J Vasc Surg. 2002;35:1123–
1128.
3. Ohki T, Veith FJ, Shaw P, et al. Increasing inci-
dence of midterm and long-term complications
after endovascular graft repair of abdominal
aortic aneurysms: a note of caution based on
a 9-year experience. Ann Surg. 2001;234:323–
335.
4. Hinchliffe RJ, Singh-Ranger R, Davidson IR, et
al. Rupture of an abdominal aortic aneurysm
secondary to type II endoleak. Eur J Vasc En-
dovasc Surg. 2001;22:563–565.
5. Laheij RJ, Buth J, Harris PL, et al. Need for sec-
ondary interventions after endovascular repair
of abdominal aortic aneurysms. Intermediate-

4. 582 PRIMARY PREVENTION OF TYPE II ENDOLEAK
Zanchetta et al.
J ENDOVASC THER
2005;12:579–582
term follow-up results of a European collabo-
rative registry (EUROSTAR). Br J Surg. 2000;87:
1666–1673.
6. Walker SR, Macierewicz J, Hopkinson BR. En-
dovascular AAA repair: prevention of side
branch endoleaks with thrombogenic sponge.
J Endovasc Surg. 1999;6:350–353.
7. Bonvini R, Alerci M, Antonucci F, et al. Preop-
erative embolization of collateral side branch-
es: a valid means to reduce type II endoleaks
after endovascular AAA repair. J Endovasc
Ther. 2003;10:227–232.
8. Ho P, Law WL, Tung PH, et al. Laparoscopic
transperitoneal clipping of the inferior mesen-
teric artery for the management of type II en-
doleak after endovascular repair of an aneu-
rysm. Surg Endosc. 2004;18:870.
9. Kasirajan K, Matteson B, Marek JM, et al. Tech-
nique and results of transfemoral superselec-
tive coil embolization of type II lumbar endo-
leak. J Vasc Surg. 2003;38:61–66.
10. van Marrewijk C, Buth J, Harris PL, et al. Sig-
nificance of endoleaks after endovascular re-
pair of abdominal aortic aneurysm: the EU-
ROSTAR experience. J Vasc Surg. 2002;35:461–
473.