Emergent Direct Puncture Embolization Using Onyx® of Type II endoleak after Endovascular Abdominal Aortic Aneurysm Repair
Heepeel Chang, MD, Njogu K. Njuguna, MD, Marc A. Norris, MD, Marvin E. Morris, MD, Neal C. Hadro, MD.
Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA.
OBJECTIVES: Re-intervention due to type II endoleak after EVAR is a vexing problem. CT-guided direct sac puncture is a useful technical adjunct in complex endoleaks. We present a successful case of emergent direct puncture embolization with Onyx® of type II endoleak occurring after EVAR with AAA expansion.
METHODS: Electronic medical records were reviewed to retrieve images, operative details and findings at presentation.
RESULTS: An 81-year old female with a history of 8.8 cm abdominal aortic aneurysm (AAA) status post EVAR complicated by type IB and III endoleak requiring bilateral iliac extensions who presented to the emergency department with increasing abdominal distension. CT angiogram (CTA) revealed an expanding AAA up to 11.1 cm with type II endoleak from a right lumbar artery. Given expanding size of the AAA, frailty of the patient, and concern for impending rupture, patient was emergently taken to the hybrid operating suite. Under intermittent CT fluoroscopy guidance, with MAC anesthesia, from a right flank approach, a 21-gauge trocar introducer needle was advanced into the aneurysm sac aimed at the L2-3 vertebral level, corresponding to the known endoleak location. Sac angiogram was performed and confirmed that the type II endoleak was primarily supplied by the right lumbar (L2) artery. Onyx® was then injected into the feeding right L2 artery. Pressure measurements were obtained in the sac, verifying that the sac was not pressurized. Post-embolization angiography and cross sectional imaging demonstrated satisfactory embolization in the lumbar artery and the endoleak nidus within the aneurysm sac.
CONCLUSIONS: A direct transabdominal puncture embolization with Onyx® can be effective to treat type II endoleaks in the emergent setting. This approach addresses both the endoleak nidus with the AAA sac and feeding vasculature and was useful due the frailty of this patient with recent expansion of her AAA.FIGURE: A. CTA demonstrating type II endoleak (arrow) from a right lumbar artery. B. Intraoperative angiogram showing type II endoleak from right L2 artery (arrow). C. Angiogram showing direct injection of Onyx® (arrow) through the KMP catheter. D. Axial slice of postoperative CTA at 6-month demonstrating no residual endoleak after embolization with Onyx® (arrow). 
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