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Preoperative Dx: Type 2 endoleak from the inferior mesenteric artery, status post endovascular repair of AAA.
Procedures:
1) percutaneous translumbar sheath access of AAA sac
2) translumbar sac aortogram
3) coil embolization of type 2 endoleak
4) embolization of type 2 endoleak with liquid endoleak
The patient was placed prone on the operating table and was sterilely prepped from the neck to the buttocks and draped in sheet to sheet. Based on preoperative CT imaging and measurements from the spine were made laterally 7.5 cm and marked on the back and under fluoroscopy, a point between the L3 and L4 vertebra was marked. Using a Jeffrey nephrostomy kit and with Seldinger technique, the needle was passed with a 30-degree angulation into the aneurysm sac and a pop was felt when it entered the sac. The inner needle was removed and there was pulsatile backbleeding from the cannula. Contrast was injected through the cannula and was seen to fill the aneurysm sac in the shape consistent with the endoleak seen on the CT scan. The 0.018 wire was passed through the cannula into the aneurysm sac followed by the 4-French sheath. A Cook hemostatic valve was placed on the back end of the 4-French sheath of the Jeffrey nephrostomy tube. A pressure was obtained by hooking this to the pressure tubing for anesthesia and the mean arterial pressure in the aneurysm sac was 76 versus the systemic mean arterial pressure of 77; there was pulsatile pressure waveform.
An angiogram was then obtained and this filled the nidus in the aneurysm sac and filled the inferior mesenteric artery in a caudad direction and a lumbar branch was seen coming off the nidus.
A 4-French angle taper catheter and Glidewire were then passed through the 4-French sheath and the Glidewire and angled tapered catheter were able to be passed into the inferior mesenteric artery down to a branch point. This branch point was approximately 4 cm below the entry point of the catheter into the nidus. A Progreat micro catheter was then exchanged for the Glidewire and the wire of the Progreat catheter was passed into that branch point and the Progreat catheter was passed down to the branch point. The wire of the Progreat catheter was removed. The inferior mesenteric artery was then filled with coils down to that branch point, but not into the branch point. The first coil was a 4 mm x 10 cm coil, followed by two 3 mm x 5 cm coils with backing up the Progreat catheter after delivering the coil to the tip of the catheter. Upon completing this, contrast was injected into the tip of the sheath and it could be seen that there was no flow into the inferior mesenteric artery. The nidus was then coil embolized through the sheath via the Progreat catheter in the nidus itself using three 20 mm x 20 cm hydro coils. Finally, two 1 mL syringes of onyx glue liquid embolic was injected into the nidus up after first filling the catheter with DMSO and flushing the catheter again at the end with 6/10 mL of DMSO. The injections were done in short boluses allowing time for the onyx to set and ultimately this filled the nidus and with completion angiography through the sheath, there was no further filling of the nidus or the IMA and there was no backbleeding whatsoever through the sheath and no pulsatile flow when hooked up to manometry. The 4-French sheath was removed and pressure was held and there was complete hemostasis.
Preoperative Dx: Type 2 endoleak from the inferior mesenteric artery, status post endovascular repair of AAA.
Procedures:
1) percutaneous translumbar sheath access of AAA sac
2) translumbar sac aortogram
3) coil embolization of type 2 endoleak
4) embolization of type 2 endoleak with liquid endoleak
The patient was placed prone on the operating table and was sterilely prepped from the neck to the buttocks and draped in sheet to sheet. Based on preoperative CT imaging and measurements from the spine were made laterally 7.5 cm and marked on the back and under fluoroscopy, a point between the L3 and L4 vertebra was marked. Using a Jeffrey nephrostomy kit and with Seldinger technique, the needle was passed with a 30-degree angulation into the aneurysm sac and a pop was felt when it entered the sac. The inner needle was removed and there was pulsatile backbleeding from the cannula. Contrast was injected through the cannula and was seen to fill the aneurysm sac in the shape consistent with the endoleak seen on the CT scan. The 0.018 wire was passed through the cannula into the aneurysm sac followed by the 4-French sheath. A Cook hemostatic valve was placed on the back end of the 4-French sheath of the Jeffrey nephrostomy tube. A pressure was obtained by hooking this to the pressure tubing for anesthesia and the mean arterial pressure in the aneurysm sac was 76 versus the systemic mean arterial pressure of 77; there was pulsatile pressure waveform.
An angiogram was then obtained and this filled the nidus in the aneurysm sac and filled the inferior mesenteric artery in a caudad direction and a lumbar branch was seen coming off the nidus.
A 4-French angle taper catheter and Glidewire were then passed through the 4-French sheath and the Glidewire and angled tapered catheter were able to be passed into the inferior mesenteric artery down to a branch point. This branch point was approximately 4 cm below the entry point of the catheter into the nidus. A Progreat micro catheter was then exchanged for the Glidewire and the wire of the Progreat catheter was passed into that branch point and the Progreat catheter was passed down to the branch point. The wire of the Progreat catheter was removed. The inferior mesenteric artery was then filled with coils down to that branch point, but not into the branch point. The first coil was a 4 mm x 10 cm coil, followed by two 3 mm x 5 cm coils with backing up the Progreat catheter after delivering the coil to the tip of the catheter. Upon completing this, contrast was injected into the tip of the sheath and it could be seen that there was no flow into the inferior mesenteric artery. The nidus was then coil embolized through the sheath via the Progreat catheter in the nidus itself using three 20 mm x 20 cm hydro coils. Finally, two 1 mL syringes of onyx glue liquid embolic was injected into the nidus up after first filling the catheter with DMSO and flushing the catheter again at the end with 6/10 mL of DMSO. The injections were done in short boluses allowing time for the onyx to set and ultimately this filled the nidus and with completion angiography through the sheath, there was no further filling of the nidus or the IMA and there was no backbleeding whatsoever through the sheath and no pulsatile flow when hooked up to manometry. The 4-French sheath was removed and pressure was held and there was complete hemostasis.
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