CT guided direct thrombin injection to treat type II endoleak - PowerPoint PPT Presentation

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 than • 50% 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 • <1 % if d< 5 cm – 10 % if d=5,5-7 cm – 33% if d > 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 technique • for repair of AAA, and in 2010, EVAR accounted for 78% of all intact AAA repair in 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 placation and 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 slow administration 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

Conclusion: Our experience CT guided direct thrombin Time & cost effective Time & cost effective injection

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