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OBJECTIVES:
Endovascular repair of aortic aneurysms is associated with decreased perioperative morbidity compared to open aneurysm repair. Between 10-25% of EVARs are complicated by an endoleak. Type II endoleak is defined as retrograde flow of blood into the aneurysm sac by aortic branch vessels. We describe a case report of a type II endoleak, with repair indicated by sac expansion, involving embolization of five arteries providing flow into the aneurysm sac, performed through a single site brachial artery percutaneous access.
METHODS:
A 74 year old man with a 5.8 cm infrarenal AAA had
undergone an EVAR two years prior. Surveillance imaging demonstrated type II endoleak from the accessory right renal artery (aRRA), inferior mesenteric artery (IMA), L3 & L4 lumbar arteries (L3A, L4A) and middle sacral artery (MSA). Using brachial access, we catheterized the superior mesenteric artery, entered the meandering mesenteric artery and thus the aneurysm sac via the IMA (Figure 1).

Angiogram confirmed sac entry with subsequent embolization of the aRRA, sac cavity and IMA with Nester platinum 0.018 inch
coils. We then accessed and embolized the MSA via the ascending lumbar branch off the posterior division of the left internal iliac artery. Next L3A and L4A were individually accessed and coil embolization was also performed.
RESULTS:
Completion angiogram showed cessation of flow into the aneurysm sac. Follow up imaging at postoperative month 1 and 5, respectively, revealed resolution of the type II endoleak with gradual aneurysmal sac shrinkage.
CONCLUSIONS:
The management of Type II endoleaks remains controversial with aneurysmal dilatation being the primary marker for intervention. Options for repair include: conversion to open surgery, suture ligation of the feeding arteries (with the aneurysm open or intact), laparoscopic ligation or clipping of the feeding arteries, coil embolization of the feeding arteries, coil embolization of the endoleak cavity, and polymer embolization of the endoleak cavity.The transcatheter therapies can be accomplished through
transarterial (usually transfemoral) or through translumbar access. Our case demonstrates that through a single site brachial arterial access, it is possible to embolize multiple arterial branches feeding the aneurysm sac. This potentially decreases the risk of access site complications.