Society For Clinical Vascular Surgery

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Transcaval Embolization of Endoleaks
Caroline M. Burley, BS, Waseem Bhatti, MD, Mark H. Kumar, MD, Christina Boyd, MD, Clifford M. Sales, MD MBA.
Overlook Medical Center, Summit, NJ, USA.

OBJECTIVE: The management of endoleaks that develop after endovascular repair of aortic aneurysms has evolved over the decades since endografts have been used to treat aortic aneurysms. Direct access to the aortic sac to control an endoleak now includes the transcaval approach. We have reviewed the safety and efficacy of this technique in complex type II aortic endoleaks in our institution.

METHODS: We have reviewed all the medical records of our patients undergoing transcaval embolization of endoleaks (TCE) over the last year. The details of the initial operation and subsequent attempts to control the complication were reviewed.

RESULTS: Nine consecutive patients (81.9 6.9yo, 78% male) presented with enlarging aortic sac diameter and documented flow within the aortic sac for TCE. The mean sac enlargement was 1.2 0.7cm and this group of patients presented 6.0 3.1 years after the index procedure. Five (56%) of the patients had prior attempts at endovascular repair of the documented endoleak. All patients underwent a percutaneous transcaval approach to the aortic utilizing the Rosch-Uchida TIPS access kit through a 10Fr sheath in a biplane angiography room. Coil embolization of the sac and/or lumbar arteries and the occasional use of a thrombin-gelfoam slurry allowed obliteration of the endoleak. All patients were admitted overnight for observation and discharged home on post-procedure day one. No complications developed during the immediate post-procedure period. All nine patients (100%) were noted to have decrease in the diameter of the aortic sac on their post-procedure study and only one (11%) had persistent (but markedly diminished) flow noted on the follow-up ultrasound. Follow-up is early and extends out to six months without recurrence of the endoleaks.

CONCLUSIONS: The ability to safely access the aortic sac through the vena cava is an efficient, safe and useful technique to treat aortic endoleaks. The avoidance of the operating theater, the relatively low cost and the absence of complications with a multidisciplinary approach (Interventional Radiologist and Vascular Surgeon) suggests this technique will likely improve the management of patients with aortic endoleaks. The cost reduction, improved patient satisfaction and, ultimately, improved outcomes addresses the triple aim of modern health care.

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