Percutaneous navigated embolization

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Text of Percutaneous navigated embolization

Nilo J Mosquera, MD.

Nilo J Mosquera, MD. Endovascular Therapy Area.Angiology and Vascular Surgery Department.Complexo Hospitalario de Ourense. CHUO. Spain

Percutaneous translumbar/transgluteal navigation-guided embolization for type II endoleaks.

A novel technique

+DisclosureSpeaker 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/AuthorYearNFollow-Up YearsSecondary Procedures (%)RCTsEVAR-12010626623EVAR-220101973.128DREAM20101736.428OVER20094441.810Case Control StudiesCarpenter20101571.88.9Conrad20108322.911Mehta20101,7682.818AbuRahma2009238226Dias20092794.520Abbruzzese20095652.511Pitoulias20096173.823Kim20083103.319Schermerhorn200822,8304.09.0LONDON 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 migrationNumber of Patients1,768Mean Follow-up [SD]34 Months [30]% with Secondary Intervention19.2% Type II Endoleak40.1% Type I/III Endoleak16.5% Migration13.6% Limb Occlusion7.4% Rupture, Device Defect, etc.8.6%

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

EVAR: Anatomy Challenges and reinterventions are related to sac enlargement and aneurysm rupture!!!Are type II endoleaks really so benign?nComplicationConclusionSchanzer A, Greenberg RK

Circulation Jun 2011

10228 patientsUS multicentric data41% patients with sac enlargement 5 years FUONLY 42% PATIENTS ANATOMY COMPLIED WITH IFU Type II endoleak and anatomical issues.Albertini JN

Ann Vasc Surg 2010 Jul157 patientsZenith StentgraftsPowerlink StentgraftsTalent Stentgrafts

1999-200817% type Ib leak8% limb oclussion

AAA + Iliac aneurysm extending to iliac bifurcationComplex iliac landing: Aneurysmal extension to iliac bifurcation increases secondary procedures and complications during FULONDON CARDIOVASCULAR SYMPOSIUM; 28-29 October 2011XIV Angiology and Vascular Surgery Oporto International Symposium 25-26 October 2013

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.EventNoYesEndoleak$5,706$26,739Secondary Intervention$3,668$31,6965-year Costs Following EVAR ($US)

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

Case & technique: report78 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 closurePostoperative 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.LONDON CARDIOVASCULAR SYMPOSIUM; 28-29 October 2011XIV Angiology and Vascular Surgery Oporto International Symposium 25-26 October 2013

Case & technique: report3 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 arteryLONDON CARDIOVASCULAR SYMPOSIUM; 28-29 October 2011XIV Angiology and Vascular Surgery Oporto International Symposium 25-26 October 2013

Case & technique: planningWe decided to treat this patient adressing the endoleak by direct puncture, so we discussed:

Direct transgluteal puncture of the gluteal artery

Aneurysm sac puncture, as Plan B, in case we werent able to achieve enough accuracy to puncture this branch of the hypogastric artery.

Primary target vessel(Transgluteal puncture)LONDON CARDIOVASCULAR SYMPOSIUM; 28-29 October 2011XIV Angiology and Vascular Surgery Oporto International Symposium 25-26 October 2013

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.).

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

Case & technique: Medtronic O-armTMThe O-ARMTM provides high quality image and real time 3D capability, also 0-360 degrees image angulation. Not specific vascular tools available.

Intraoperative CT control (post preocedure)

Image assistance in complex AAA therapy (fenestrated/branched grafts)LONDON CARDIOVASCULAR SYMPOSIUM; 28-29 October 2011XIV Angiology and Vascular Surgery Oporto International Symposium 25-26 October 2013

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