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Object:
Type 2 endoleaks after EVAR can be difficult to approach and treat using typical translumbar or transarterial embolization. We previously reported anterior trans abdominal embolization in a patient with a large AAA distending the abdominal wall.
Method:
We report two cases of type 2 endoleak treated with a previously undescribed technique, laparoscopic directed anterior embolization (LDAE)
Results:
An 87-year-old female presented two years after her initial EVAR with a type 2 endoleak and sac enlargement. Translumbar and transarterial embolization had previously been attempted. The anterior-posterior orientation of the feeding lumbar indicated that an anterior approach would increase the likelihood of cannulation.
A 97-year-old male with chronic kidney disease (CKD; baseline creatinine of 3) was found to have a 9.3cm aneurysm sac and a type 2 endoleak three years after EVAR. The orientation of the feeding vessel and the patient’s CKD rendered a prolonged transarterial attempt undesirable. LDAE was thought to provide most direct access to the target vessels.
For both patients, access was gained to the abdominal cavity with a 2-mm Veress needle, and the abdomen was insufflated with CO2, allowing for insertion of two 3-mm trocars in the right mid abdomen. Several loops of small bowel were moved to allow for direct visualization of the anterior aortic wall. An 18-gauge needle was introduced via the anterior abdominal wall and punctured the aneurysm sac under direct vision. Fluoroscopy was used at this time to avoid puncture of the endograft. After introduction of a wire, a 4-French sheath was introduced to the aneurysm sac. Feeding lumbar arteries were cannulated using a Bern catheter and embolized using both microcoils (Boston Scientific) and Onyx (Medtronic), with good angiographic result. The abdomen was re-insufflated, and the sheath was then removed from the aneurysm sac under direct vision with minimal bleeding. The abdomen was desufflated and the patient was taken to recovery. Both patients tolerated the procedure well and were subsequently discharged home on postop day 2 and 7.
Conclusion:
This is the first report of LDAE. The procedure is easy, the patients recovered rapidly and it provides a more direct approach to the target vessels. This technique should be considered when traditional transarterial and translumbar approaches have failed.