Aorta

Transprosthetic embolization

Would you be able to determine the most effective treatment plan for a 73-year-old patient whose aneurysm sac has enlarged after two years of stability post-endovascular repair of an abdominal aortic aneurysm? Examine this clinical case and contrast your treatment approach with that of your peers!

Éric Ducasse
Éric Ducasse
Hospital: Pellegrin, Bordeaux, France

Professor of vascular surgery
Head of unit of vascular surgery CHU Bordeaux - France

Conflicts of interest:

Honoraria from: COOK Médical, Térumo-Vascutek, Siemens, GORE

Part I - Case presentation
  • The patient is a 73-year-old man
  • He has a medical history of high blood pressure
  • 2020: previous Anaconda EVAR (EndoVascular Aneurysm Repair) for AAA (Abdominal Aortic Aneurysm) 62 mm treatment
  • 2020-2022: aneurysmal sac stability with type 2 endoleak ; AAA diameter 44 mm (vs 62 mm before surgery)
  • Since February 2023, an enlargement of the aneurysm sac has been observed, at a rate of + 5 mm in one year.
Arterial
Portal
Type 2 endoleak from sacro-lumbar arteries and AMI exit
Type 2 endoleak from sacro-lumbar arteries and AMI exit

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Part II - Treatment
  • The chosen option is transgraft direct embolization
  • To carry out this procedure, here is the list of required material:
    • Steerable sheath 7 Fr
    • Needle Catheter
    • Stiff 0.018 guidewire
    • Coils
    • Glue
  • Planned way and devices used: 
    • A transprosthetic puncture was performed using a BeBack® (Bentley) 360° rotating crossing catheter.
    • A specific stiff 0.018 ThruwayTM guidewire (Boston Scientific) was also used.
Planned way
Transprothetic puncture within the Anaconda endoprothesis
CFA 12 Fr sheath: Creation of a passage through the graft with the BeBack® system +/- steerable 7 Fr Sheath
Dilatation of the passage with a 4 mm balloon

Description of the BeBack® catheter with 0.018 distal needle, used (+/- with a 7 Fr steerable catheter) to puncture and perforate the graft in order to reach the liquid in-sac phase.

Insertion of a 0.035 support catheter
Arteriography (sacculography) of the aneurysm, which shows that the culprit sacro-lumbar arteries are permeable.

Beginning of the embolisation... It is necessary to fill until the liquid phase is complete.
 

21 coils later... The use of glue (Onyx™ liquid embolic system) is crucial to completely fill the liquid phase and stop the diffusion and circulation of blood.

The procedure should be completed by closing with a leg endoprosthesis (Gore® PLC161000).
 

Close the door with leg endoprothesis (Gore® PLC161000)

Final result: lumbar arteries with liquid space completely coiled and filled with glue.

The Final Result with lumbar arteries + liquid space complete coiling and glue filling

Follow-up

  • It is crucial to carefully follow up the treated patient with a US duplex at 6 months and an AngioCT scan at 1 year, with maximum diameter and global volume determination and comparative evaluation.
  • Advantages of this technical aspect:
    • Direct access to the liquid phase and in-sac navigation to determine and reach the inflow and outflow arteries
    • Selective inflow (+/- outflow) embolization + complete liquid space coiling and filling with large glue administration and diffusion.