Experience with new techniques for the treatment of type II endoleaks post-EVAR.

Endovascular aneurysm management (EVAR) is hampered by persistent arterial blood flow in the aneurysm sac after treatment, known as endoleak (EL). Type II EL consist of blood flow from one or more aortic branch vessels; they only require treatment when the aneurysm sac fails to shrink. Post-EVAR follow up is mostly done with contrast enhanced computed tomography. If a type II EL requiring treatment is found, a variety of options exist, depending on the source of EL and the anatomy. Inferior mesenteric artery EL is best treated by endovascular embolization through the superior mesenteric artery and Riolans' arc. In hypogastric to lumbar artery EL success of endovascular treatment is limited. In these cases a successful embolization of the EL can often be performed by a direct percutaneous approach to the EL inside the aneurysmal sac. CT guidance provides a good way to exactly puncture the EL percutaneously in most cases, but limited workspace and lack of fluoroscopy availability for the ensuing catheter manipulation hampers this technique. A novel way to puncture the EL and subsequently treat it is performed on flat panel detector angiography units. By a rotation around the patients these units provide the possibility to create a cone-beam CT (CBCT) in the angio suite. Using the 3-dimensional dataset thus acquired, a needle path can be planned and the EL nidus can be punctured with great confidence and without danger of inadvertently perforating vital structures. After the EL has been punctured, microcatheters can be inserted to embolize the origins of branch vessels and/or the aneurysm sac can be filled with thrombogenic agents or glue. CBCT guided procedures incur lower radiation dose and have higher accuracy compared to conventional CT guided procedures. Details of CBCT guided procedures; the materials and technique used are detailed in this manuscript.