CT guided direct thrombin injection to treat type II endoleak following endovascular repair of abdominal aortic aneurysm

Emmanuel Karras, Alexandros Tzeferakos, Georgios Kyprianos, Ioanna Vlachou, Sotirios Giannakakis Georgios Giannikouris, Ioanna Staikidou, Constantinos Pikoulas, Georgios Mantzikopoulos, Christoforos Maltezos, Constantinos Kokkinis

Department of Radiology, KAT General Hospital Athens, Greece

Objective

Report our experience in treating type II endoleaks with this particular method

• Localized enlargement of the aortic lumen diameter (d>3 cm) or more than50% larger than normal diameter

• AAAs affect 2 - 8% of males and 0,5 – 2 % of females over the age of 65

• Can be characterized by – its size (ectatic, moderate, severe)– its shape (fusiform, saccular, pseudo-)– Its location (thoracic, thoracoabdominal, abdominal supra-, para-, juxta- & infrarenal etc)

• Risk factors: genes, smoking, hypertension,hyperlipidemia, chronic inflammation etc.

• Rapture Risk– 7 cm

• Treatment– Open surgery– EndoVascular Aneurysm Repair (EVAR)

EndoVascular Aortic Repair (EVAR)

• Minimally Invasive technique

• In 2003, EVAR surpassed open aortic surgery as the most common techniquefor repair of AAA, and in 2010, EVAR accounted for 78% of all intact AAA repairin the United States

• Placement of an expandable stent graft within the aorta to treat aortic disease– Techniques: Standard, percutaneous, fenestrated, branched, hybrid– Most commonly inserted from femoral artery

• Complications– Procedure related: Arterial dissection, contrast-induced renal failure,

thromboembolizaton, ischemic colitis, groin hematoma, wound infection,type II endoleaks, myocardial infarction, congestive heart failure, cardiac arrhythmias, respiratory failure

– Device related: Endograft migration, aneurysm rupture, graft limb stenosis/kinking, type I/III/IV endoleaks or stent graft thrombosis

Endoleaks

An endoleak is a leak into the aneurysm sac after EVAR

Five types:

• Type I – Perigraft leakage at attachment sites • Type II a/b – from one (type a) or more (type b) AA branches

– most common endoleak (occur in 10% to 30% of patients at any time during follow-up)

– least serious type of endoleak, do not require immediate treatment– collateral retrograde flow from the aortic branches (lumbar arteries,

inferior mesenteric artery, middle sacral artery)

– a portion will resolve spontaneously• Type III – Leakage between overlapping parts of the stent or rupture through

graftmaterial

• Type IV – Graft wall failure• Type V – Non identifiable leak. Also called "endotension“

Endoleak treatment

– Sac growth of > 5 mm or persistent endoleak > 6 months– Transfemoral embolization, translumbar direct sac embolization,

transfemoral transsealing embolization, open and laparoscopic ligation of the lumbar and mesenteric arteries, aneurysm sac placationand open conversion

Thrombin

•Serine protease enzyme

•Thrombin converts soluble fibrinogen into insoluble strands of fibrin

•Catalyzes many other coagulation-related reactions

• 9 patients with CTA confirmed Type II endoleak

• Toshiba Activion™ 16 Multislice Helical CT System

• Patients full medical backround check– No reported patient allergies– Thrombophilias, blood thinners – Blood test confirmed normal renal and

Thyroid function

• Iopromide 370 mg I/mL Contrast

• 22/20 gauge Needle(s), non-traumatic

• 5-10ml Lidocaine for local anesthesia

• Recombinant human thrombin Hemostatic Matrix KIT– A mixture of thrombin powder, Sodium Chloride, and

Gelatin Matrix

1. Initial CT Angiography for confirming feeding artery/ies

1. Determining the point of thrombin administration for maximal efficacy

1. Careful selection of insertion pathway angle and distance– translumbar muscle window– Avoid intestinal helixes, major arteries and nerves

2. Topical anesthesia for patient comfort– 5 to 10 ml Lidocaine at point of needle insertion– 1 to 3 cm in depth subcutaneously– Aspiration before administration

3. Stepwise propagation of the needle

7. Once the needle is at the optimal place – continuous slowadministration of thrombin solution

• 8 patients with complete resolution of the endoleak on post injection CTA and follow up CTA after 24h, 3 & 6 months

• 1 patient with type IIb - partial resolution at CTA after 24h and complete resolution at follow up CTA after 1 month

Time & cost effectiveTime & cost effective

CT guided direct

thrombin

injection

Conclusion: Our experience

Bibliography

• Chaikof EL, Blankenteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002; 35(5): 1048–1060.

• Veith FJ, Baum RA, Ohki T, Amor M, Adiseshiah M, Blankensteijn JD et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at an inter- national conference. J Vasc Surg 2002; 35(5): 1029–1035.

• Greenberg R, Green RJ. A clinical perspective on management of endoleaks after abdominal aortic endovascular aneurysm repair. J Vasc Surg 2000; 31(4): 836–837.

• Haulon S, Willoteaux S, Koussa M, Gaxotte V, Beregi JP, Warembourg H. Diagnosis and treatment of type II endoleak after stent placement for exclusion of an abdominal aortic aneurysm. Ann VascSurg 2001; 15(2): 148–154.

• HaulonS,TyaziA,WilloteauxS,KoussaM,LionsC,BeregiJP. Embolization of type II endoleaks after aortic stent-graft implan- tation: technique and immediate results. J Vasc Surg 2001; 34(4): 600 –605.

• Baum RA, Cope C, Fairman RM, Carpenter JP. Translumbar embolization of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms. J Vasc Interv Radiol 2001; 12(1): 111–116.

• Van den Berg JC, Tutein RP, Casparie JW, Moll FL. CT-guided thrombin injection into aneurysm sac in a patient with endoleak after endovascular abdominal aortic aneurysm repair. AJR 2000; 175: 1649–1651.

• Wisselink W, Cuesta MA, Berends PJ, van den Berg FG, Rauwerda JA. Retroperitoneal endoscopic ligation of lumbar and inferior mesenteric artery as treatment of persistent endoleak after endovascular aortic aneurysm repair. J Vasc Surg 2000; 31: 1240 – 1244.

• Gorich J, Rilinger N, Sokiranski R. Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric approach. J Endovasc Ther 2000; 7(4): 297–301.

Bibliography

• M. Herrando Medrano, A.C. Marzo Álvarez, C. Lapresta Moros, M.I. Rivera Rodríguez, A.C. Fernández-Aguilar Pastor, M. Parra Rina. 2014. Inyección intraoperatoria de trombina como método de prevención de fugas tipo II en el tratamiento endovascular de los aneurismas de aorta abdominal. Angiología 66:4, 173-182

• Naoki Toya, Yuji Kanaoka, Takao Ohki. 2014. Secondary interventions following endovascular repair of abdominal aortic aneurysm. General Thoracic and Cardiovascular Surgery 62:2, 87-94

• E. Casula, E. Lonjedo, M.J. Cerverón, A. Ruiz, J. Gómez. 2014. Review of pre- and post-treatment multidetector computed tomography findings in abdominal aortic aneurysms. Radiología (English Edition) 56:1, 16-26. E.

• Casula, E. Lonjedo, M.J. Cerverón, A. Ruiz, J. Gómez. 2013. Revisión de aneurisma de aorta abdominal: hallazgos en la tomograJa computarizada multidetector pre y postratamiento. Radiología .

• Kamal Massis, William G. Carson, Alexandra Rozas, Vishal Patel, Bruce Zwiebel. 2012. Treatment of Type II Endoleaks With Ethylene-Vinyl-Alcohol Copolymer (Onyx). Vascular and Endovascular Surgery 46:3, 251-257.

• 6.Isao Nishijima, Ryo Ikemura, Masuichi Gushiken, Kazufumi Miyagi, Kiyoshi Iha. 2012. Nonsurgical treatment of scalp arteriovenous malformation using a combination of ultrasound-guided thrombin injection and transarterial coil embolization. Journal of Vascular Surgery 55:3, 833-836.

• Joyce E. P. Vrijenhoek, Albert J. C. Mackaay, Sandra A. P. Cornelissen, Frans L. Moll. 2011. Long-Term Outcome of Popliteal Artery Aneurysms After Ligation and Bypass. Vascular and Endovascular Surgery 45:7, 604-606. [Crossref]

• F. Schellhammer, M. Cohnen, G. Furst, U. Modder. 2011. Minimally invasive application of thrombin in the treatment of pseudoaneurysms following open aortic surgery. Acta Radiologica 52:1, 48-51

• Jip L. Tolenaar, Jasper W. van Keulen, Vanessa J. Leijdekkers, Evert-Jan Vonken, Frans L. Moll, Joost A. van Herwaarden. 2010. A ruptured aneurysm after stent graft puncture during computed tomography-guided thrombin injection. Journal of Vascular Surgery 52:4, 1045-1047