Type 2 endoleak treatment: an artistic superselective catheterisation

Clinical History

Man, 73 years old. In January 2008 he underwent EVAR treatment for abdominal aortic aneurysm (AAA). Follow-up CT detected small type 2 endoleak from inferior mesenteric artery (IMA) which increased in size in the follow-up at two years (Fig. 1a, b). An attempt of endovascular embolisation of IMA was scheduled.

Imaging Findings

Selective angiogram of superior mesenteric artery confirmed hypertrophic aspect of Riolano arcade (Fig. 2a). After superselective catheterisation of middle colic artery with a 4F hydrophilic catheter (Cobra2-Tempo-Aqua, Cordis) the retrograde filling of inferior mesenteric artery (IMA) and type 2 endoleak were clearly demonstrated (Fig. 2b). With a microcatheter (Prowler-Cordis) in combination with a microguidewire (Agility-Cordis) the Riolano arcade and the IMA were easily surfed until the tip of the microcatheter reached the endoleak. Microcoils (Interlock Detachable Coils and Guglielmi Detachable Coils, Boston) were deployed in the sac and at the origin of the IMA (Fig. 2c, d). Final check shows proximal occlusion of the IMA (Fig. 3a). Looking at the result we were impressed by the "artistic" result of our superselective catheterisation and we found similarities with Picasso paintings! (Fig. 3b). Follow-up of this case did not show new endoleaks.

Discussion

One of the major concerns of EVAR is related to reperfusion of the aneurysmatic sac through collaterals (lumbar arteries or IMA). This occurrence is known as type 2 endoleak (EL) and it is a cause of treatment failure and may be responsible of enlargement of the aneurysmatic sac and delayed rupture of the aneurysm. In order to avoid reperfusion by IMA different therapeutic strategies are available: preoperative [1, 2] or postoperative embolisation [3], laparoscopic ligation or expectant management [4]. Some authors [1, 2] suggest embolisation of all patent IMA before EVAR basing on their results. In their experience the authors report an inferior number of type 2 EL comparing the group of patients with patent IMA which underwent coil embolisation to a similar group of patients with patent IMA which did not undergo IMA embolisation before EVAR either at 1 month and 6 months (respectively 17-25% vs 48-59%) and no type 2 EL IMA related were detected in the patients previously treated. The other strategy is based on the postoperative treatment of type 2 EL from the IMA to be done only in cases of a significant EL responsible of aneurysmatic sac enlargement. The technique requires selective catheterisation of SMA and middle colic artery followed by superselective catheterisation of Riolano arcade and IMA. This technique was described in 2000 by Baum et al [3]. The case shown here is an example of how this type of treatment can be done. In our 12 years experience on EVAR we attempted postoperative IMA embolisation through Riolano arcade in 6 cases and we were able to reach the target in 5/6 cases. Sometimes the procedure is very challenging but with the continuous evolutions of materials (microcatheters and microguidewires) and devices (microcoils) the result can be achieved in a high percentage of cases and as in the case shown here, sometimes, with a very unexpected artistic result!

Differential Diagnosis List

Final Diagnosis

Endovascular treatment of type 2 endoleak after EVAR

URL:	https://www.eurorad.org/case/9769
DOI:	10.1594/EURORAD/CASE.9769
ISSN:	1563-4086