Percutaneous navigated embolization

+

Nilo J

Mosquera, MD.

Endovascular Therapy

Area.

Angiology and

Vascular Surgery

Department.

Complexo Hospitalario

de Ourense. CHUO.

Spain

Percutaneous

translumbar/transglut

eal navigation-

guided embolization

for type II endoleaks.

A novel technique

Disclosure

Speaker name:

Nilo J Mosquera, MD.

x I have the following potential conflicts of interest to report:

x Consulting: Lombard Medical, Cook Medical, WL Gore, Medtronic,

Endologix.

Employment in industry

Shareholder in a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

XIV Angiology and Vascular Surgery Oporto International Symposium – 25-26 October 2013

Great Challenge for EVAR was to avoid

secondary reintervention: this remains today

Trial/Author Year N Follow-Up Years Secondary

Procedures (%)

RC

Ts

EVAR-1 2010 626 6 23

EVAR-2 2010 197 3.1 28

DREAM 2010 173 6.4 28

OVER 2009 444 1.8 10

Ca

se

Co

ntr

ol S

tud

ies

Carpenter 2010 157 1.8 8.9

Conrad 2010 832 2.9 11

Mehta 2010 1,768 2.8 18

AbuRahma 2009 238 2 26

Dias 2009 279 4.5 20

Abbruzzese 2009 565 2.5 11

Pitoulias 2009 617 3.8 23

Kim 2008 310 3.3 19

Schermerhorn 2008 22,830 4.0 9.0

LONDON CARDIOVASCULAR SYMPOSIUM; 28-29 October 2011XIV Angiology and Vascular Surgery Oporto International Symposium – 25-26 October 2013

Most important issues related to

reintervention Type I, II and migration

Number of Patients 1,768

Mean Follow-up [SD] 34 Months [30]

% with Secondary Intervention 19.2%

Type II Endoleak 40.1%

Type I/III Endoleak 16.5%

Migration 13.6%

Limb Occlusion 7.4%

Rupture, Device Defect, etc. 8.6%


EVAR: Anatomy Challenges and reinterventions are related to sac enlargement and aneurysm rupture!!!

Are type II endoleaks really so benign?

n Complication Conclusion

Schanzer A,

Greenberg RK

Circulation Jun 2011

10228 patients

US multicentric data

41% patients with

sac enlargement

5 years FU

ONLY 42% PATIENTS

ANATOMY COMPLIED

WITH IFU

Type II endoleak and

anatomical issues.

Albertini JN

Ann Vasc Surg 2010 Jul

157 patients

Zenith® Stentgrafts

Powerlink®

Stentgrafts

Talent ® Stentgrafts

1999-2008

17% type Ib leak

8% limb oclussion

AAA + Iliac aneurysm

extending to iliac

bifurcation

Complex iliac landing:

Aneurysmal extension

to iliac bifurcation

increases secondary

procedures and

complications during FU


EVAR complications represent clinical

also economical challenges!!!

“Efforts aimed at minimizing cost should

emphasize technical and device modifications

aimed at reducing endoleaks and the need for

secondary procedures.”

Noll RE, et al. J Vasc Surg 2007;46:9-15.

Event No Yes

Endoleak $5,706 $26,739

Secondary Intervention $3,668 $31,696

5-year Costs Following EVAR ($US)


Case & technique: report

78 years old male with a complicated Aorto-bi-iliac aneurysm treated in 2009 with

aortouniiliac conversion of a Aorfix bifurcated endograft (Lombard Medical) due

to intraoperative rupture.

The bifurcated (28-111-63-12) endograft was converted to aortouniiliac with a (29

mm) Aorfix converter with distal sealing at right external iliac. A femoro-femoral 8

mm supported dacron graft by-pass and left common femoral surgical closure

Postoperative CT scan showed a type II endoleak but no active bleeding or

retroperitoneal haemathoma increase. Patient was discharged from ICU 36 hours

after procedure and 7 days after he was discharged from the hospital.

Regular FU protocol was performed (CT scan at 1, 6 and 12 months after

procedure) showing sac stability and 5 mm reduction at 18 months so we

continue anually.


Case & technique: report

3 years FU CT scan showed significative increasing in both sac diameter and

volume and no other modifications; the type II endoleak remained related to left

hypogastric artery.

Volume calculation:

20% increase Type II endoleak: patent left hypogastric artery


Case & technique: planning

We decided to treat this patient adressing the endoleak by direct puncture, so we

discussed:

1. Direct transgluteal puncture of the gluteal artery

2. Aneurysm sac puncture, as Plan B, in case we weren´t able to achieve enough

accuracy to puncture this branch of the hypogastric artery.

Primary target vessel

(Transgluteal puncture)


Case & technique: Medtronic O-armTM and

Stealth Station Treon PlusTM

The O-ARMTM System (Medtronic, Minneapolis, US.) is an intraoperative

imaging device based on Conic Beam X-Ray technology

This system is capable to obtain, intraoperatively, images quite similar to

regular CT scan, also 3D and multiplanar reconstructions.

The O-Arm combines with the proper navigation system: Stealth Station

Treon PlusTM(Medtronic, Minneapolis, US.).


Case & technique: Medtronic O-armTM

The O-ARMTM provides high quality image and real time 3D capability, also

0-360º degrees image angulation. Not specific vascular tools available.

Intraoperative CT control

(post preocedure)

Image assistance in complex AAA therapy

(fenestrated/branched grafts)


1. Position at the table after general anesthesia

Patient position and reference:

Under general Anesthesia

2. Potential puncture site

3. Intended position for PerPin

4. Punture/PerPin distance (ideal<20cm)


Patient position and preparations:


5. O-ARM in place.

6. Overview Surgical site.

7. Specific Navigation tools.



8. 5 mm incision for PerPin.


9. PerPin secured to iliac bone




10. Navigation references in place 11. Translumbar needle and virtual tool

Target Location: Gluteal arteryresponsible for type II


Transgluteal Navigated

puncture of gluteal artery

Exchange for haemosthatic

valve and cannulation

Transgluteal punture:

Puncture and Cannulation


Access achieved:

hypogastric type II

leak identified

Coil deployment for type II

endoleak nidus

Transgluteal punture: Embolization


Hypogastric trunk embolization: OnyxTM.


OnyxTM applied to nidus, hypogastric trunk (& access to achieve hemosthasis)

Patient discharged from hospital

18 hours after the procedure

Results: inmediate FU

30 days results were positive, no

inmediate complications.

3 months angioCT FU showed

successful exclusion of the type

II endoleak and aneurysm sac

stability.


Navigation guided surgery is a promising concept to apply

in different disciplines than neurosurgery, currently there are

initial experiences in vascular surgery.

Results: comments

The Medtronic O-ArmTM intraoperative cbCT is a powerful tool toobtain high quality tomographic images in real time and combine with navigation systems. This technique allows the surgeon toperform highly accurated navigated procedures.

Transgluteal or translumbar direct percutaneous Access is a usefulapproach to treat this kind of complication following EVAR, navigation access seems to be far more simple and accurate thanprevious C-Arm or CT alone guidance.


+

Nilo J

Mosquera, MD.

Endovascular Therapy

Area.

Angiology and

Vascular Surgery

Department.

Complexo Hospitalario

de Ourense. CHUO.

Spain

Thank you!!!

Documents

Percutaneous navigated embolization