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Transcaval Access Provides a Safe and Effective Method in the Treatment of Type II Endoleaks
Tareq Massimi, Sira Duson, Steven Abramowitz, Rajesh Malik, Misaki Kiguchi, Edward Woo.
Medstar Heart and Vascular Institute, Washington, DC, USA.

Objective: We aim to describe our technique and preliminary results of transcaval access for treatment Type II endoleaks status post EVAR.
Methods: We performed a retrospective review of a prospective data registry collected from January 1st 2015 to March 1st 2016.Our standardized technique is described as follows. Under fluoroscopic guidance, a 19-gauge transjugular liver biopsy needle is passed via transfermoral venous access through the inferior vena cava into the aneurysm sac at the site of maximal aorto-caval apposition. Confirmation of sac entrance is confirmed by anterior/posterior and lateral fluoroscopic and angiographic imaging. Over a stiff wire, a sheath and catheter are then introduced into the aneurysm sac. Transarterial, intra-aortic angiography facilitates localization of the endoleaks. The intra-sac catheter and wire are used to catheterize the osteum of the vessel responsible for Type II endoleak. Coil embolization of the catheterized vessel or of the vessel osteum is performed.Technical success was defined as resolution of the endoleak on repeat intraarterial angiography. Additional outcome measures included resolution of the type II endoleak and aneurysm sac expansion upon follow-up imaging. CT angiography was obtained for all patients except those with Stage 3 or greater chronic kidney disease. Abdominal aortic duplex was used to determine the presence of endoleak in these patients.
Results: Four patients underwent transcaval embolization for an expanding aneurysm sac. Seventy five percent of the patients were male. The average age was 78.7 years old. Average pre-intervention aneurysm sac size was 8.5cm (6.7-10.6cm). Two patients had failed previous transarterial/translumbar embolization attempts. The technical success rate for transcaval embolization was 100%. The average fluoroscopy time was 34.6 minutes. The average amount of contrast administered was 60mL. The number of coils deployed averaged 8.75 (from 3 to 11). There were no immediate post operative complications. Follow-up ranged from 1-12 months. All patients remained free of endoleaks with stable or decreasing aneurysm sac size. No patients developed any complications associated with the IVC or femoral veins.
Conclusions: Transcaval access is a safe and effective alternative method for treating Type II endoleaks. In addition, it can be considered a as primary or secondary approach after failed intraarterial or translumbar attempts.


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