Endoleaks : graft extension or coil embolization ?
Claudio Schönholz,MD
Associate Professor of Radiology
Heart and Vascular Center
Medical University of South Carolina
Charleston, SC
CANNES 2004

“Presence of flow at the aneurysmal sac after stent-graft treatment”
White GH, May J, Waugh RC, Chaufour X, Yu W.
Type III and type IV endoleak: toward a complete definition of blood flow in the sac after endoluminal AAA repair. J Endovasc Surg 1998;5:305309.

Endoleak Types
• Type I endoleak
Proximal or distal attachment
•
Type II endoleak
Retrograde branch flow
• Type III endoleak
Structural defect or component junction
•
Type IV endoleak
Trans-graft leakage or porosity

• Case Selection
• 20 % oversizing of the endograft.
• Generous overlapping of segments.
• Graft covers the aorta and common iliac arteries from the renal arteries down to the iliac artery bifurcation.

Possible reasons of having low incidence of Type I endoleaks :
• No procedure was considered finished until complete sealing of the endograft was obtained.
• Sealing of the ends and connections was achieved by applying balloon dilatation, cuffs and malleable stents at the ends ( Extra-large
Palmaz)
PARODI, JC

Prevention of Type II Endoleak:
IMA Embolization

Prevention of Type II Endoleak:
Lumbar Artery Embolization

WHEN SHOULD TYPE II
ENDOLEAKS BE TREATED?
6-month CT scan
“If the endoleak continues to be present on the 6month scan, there is a small chance that it will spontaneously thrombose”
• Treat a type II endoleak if there is evidence of sac enlargement
• Intervene if a type II endoleak is present on the 6month scan regardless of the status of an aneurysm sac

• Simple: small cavity and has ingress and egress from a single vessel
• Complex: multiple ingress and egress vessels

ENDOLEAK ANATOMY
“
• Blood enters during systole into the endoleak cavity, swirling around, leaving the endoleak cavity during diastole
• Physiology similar to a pseudo-aneurysm
• May spontaneously thrombose prior to the
6-month CT scan

ENDOLEAK ANATOMY
“Complex”
• Multiple ingress and egress vessels
• Behave like arteriovenous malformations
• Persists longer than 6 months.

How to treat Type II Endoleaks:
Embolize the artery feeding the endoleak cavity by a transarterial route ?
• This technique has proved ineffective, providing only short-term response if the sac can not be reached by the embolic agent.
• Endoleaks will recur by recruiting additional aortic branch vessels.

The endoleak cavity acts as an
“Arteriovenous malformation nidus,” and thrombosing this nidus is what provides a successful and durable response.
Richard A. Baum, MD
Do stable type II endoleaks require treatment after EVAR
Endovascular Today

Type II Endoleak:
Embolization with Glue

•67 Years old High Risk Patient.
•6.5 cm AAA treated 14 month ago with Gore
Excluder Device.
•CT scan showed Type II Endoleak from IMA and the AAA remain same size.
•Indication:Endovascular Embolization

How to treat Type II Endoleaks: translumbar needle stick ?
• Coils and glue to completely thrombose the endoleak cavity
• Instead of treating feeding vessels, the endoleaks themselves are being embolized
• The connection between ingress and egress vessels, as well as the endoleak cavity, is destroyed

Translumbar Gelfoam-Thrombin 6 Months FU

Translumbar Embolization of Type 2
Endoleaks after Endovascular Repair of
Abdominal Aortic Aneurysms
• 7 Patients with Type 2 Endoleak
• 4 lumbar, 3 IMA
• 19-gauge,20cm needle w/5fr.Teflon Sheath
• Gianturco Coils (CooK)
• 100% Initial Success
• No Complications
R.A.Baum;C.Cope; R.Fairaman;J.Carpenter
J.Vasc Interv Radiol 2001;12:111-116

• Type I: Immediate treatment.
Balloon,Cuff, Palmaz or Conversion to
Open Procedure.
• Sealed Type I: If large Treat ,If small
Watch. If size does not decrease Treat.
• Type II: Treat after 6 months if aneurysmal size do not decrease.
• Late Type I or III: Treat immediately.

Obliteration of the Aneurysmal
Sac in Abdominal Aortic
Aneurysms in an Animal Model
Renan Uflacker,MD

Pig #3
AAA creation
Endoleak
Volume measurement
15 cc’s
Post Treatment

24 Week FU
Pig # 3

• The treatment of the AAA was technically successful in all animals with total exclusion of the sac
• The AAA sac acquired a firm rubberish consistency after treatment
• Fibrosis and calcifications were detected within the sac, mostly around the graft and in contact with the aortic wall after 4 to 6 weeks.
• There was inflammatory reaction to the Dacron material and to the polymer (to a lesser extent)
• Significant adhesion of the AAA with surrounding structures was observed

• After 4 to 6 weeks there is a tendency for shrinkage of the AAA sac, apparently maximized by the 24 th week
• There was no sac recanalization in the follow up time ranging from 1 to 24 weeks
• The controls at 6 and 12 weeks showed shrinkage of the AAA sac (histology not ready yet)

• pGlcNAc Glucosamine in the gel form is an unique hemostatic material
• Promotes rapid clotting within the AAA sac
• Also effective under systemic anticoagulation
• Effective aneurysm sac filling with occlusion of branches as necessary
• Easy to use and cost effective
• It seems to have gradual longer term absorption allowing
AAA shrinkage over a period of 24 weeks but not before 6 weeks
• Experience is necessary for volumetric measurement
• A human trial is warranted