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Objectives: Preemptive selective coil embolization of inferior mesenteric artery (IMA) and/or lumbar arteries (LA) as well as embolization of perigraft sac using coils and thrombin for prevention of type 2 endoleak (T2EL) has been described, but has not been adopted. T2EL is reported to increase 6 to 18-fold with increasing number of patent LA, IMA, and lumen diameter. We hypothesized that using preemptive non-selective perigraft aortic sac coil embolization (PNPASEC) at the time of graft insertion in patients with ≥4 patent LAs, IMA (≥3mm) and ≥30mm aortic patent lumen would decrease T2EL and compared T2EL rates before and after this approach was adopted.
Methods: 210 patients underwent EVAR between 12/2001-03/2011 and 125 between 4/2011-2/2014. All but 2 meeting the above criteria in the second period had PNPASEC. In our technique, a separate wire is advanced into the sac after cannulating the contralateral gate, sheath is reinserted and graft deployment is completed with both iliac extensions. The contralateral sheath is reinserted over the wire in the sac, and a 5F catheter is advanced around the iliac limb into the sac. A ‘sacogram’ is performed and large coils are deployed until there is significant reduction or no flow. Wire/sheath are removed, sheath is reinserted and iliac limb is molded with the balloon before completion angiogram.
Results: Nine PNPASEC were performed (8 EVAR, 1 FEVAR, all percutaneous). Mean aortic sac size was 60±7mm (53-73), mean lumen diameter 45±11mm (36-68mm), mean number of patent LAs 5.4±0.7 (4-6); 3 had accessory renal arteries, and all had patent IMAs (4mm (3-5)). Sac diameter decreased or was stable in 8 cases (mean 15 month follow-up). T2EL with sac increase was seen in 16 (7.6%) in first period (14 underwent transarterial/translumbar coiling), and 3 (2.4%) in second period (P=0.046), 2 of whom met the criteria but did not have PNPASEC. The only failure in PNPASEC group (11%) had 2 accessory renal arteries and required transarterial coil embolization 23 months after EVAR. One of the remaining 2 had translumbar coil embolization 19 months after EVAR. The other died at 24 months of unknown causes and had refused treatment.
Conclusions: Selective use of PNPASEC with above-mentioned technique may be effective in preventing development of T2EL in carefully selected patients (7%) with high anatomic risk.