Embolization of a Type II Endoleak Using Onyx

Resident(s): Sumeet Bahl, MD

Fellow(s): Steve Steer, MD
Attending(s): Adie Friedman, MD; Joseph Shams, MD
Program/Dept(s): Mt. Sinai St. Lukes-Roosevelt; Mt. Sinai Beth Israel

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation
Status post EVAR with enlarging type II endoleak, request for embolization.

History of Present Illness

91-year-old female with PMH of incidental 6cm infrarenal AAA status post EVAR (2007)
complicated by type Ia endoleak treated with a fenestrated endograft at an outside
hospital.
Follow up CT showed growth of aneurysm sac to 8cm due to a type IIb endoleak, treated
with glue/coil embolization of feeding right hypogastric artery branches x2 by Vascular
Surgery.
Follow up outside CT showed persistent type II endoleak and the patient was admitted
for Onyx embolization of feeding arteries by IR.
The patient denied abdominal or back pain, lower extremity paresthesias or motor
weakness, or fecal or urinary incontinence.

RELEVANT HISTORY
Past Medical History
AAA, hypertension, hyperlipidemia, chronic anemia, hepatitis C

Past Surgical History

EVAR (2007), fenestrated endograft placement for type Ia endoleak, coil/glue embolization of type
IIb endoleak (Oct. 2014), left total knee arthroplasty (2004), colon resection (2003), open
appendectomy (1940s)

Family & Social History

No history of tobacco or significant EtOH use
Son had ruptured AAA s/p open repair

Review of Systems: As per hpi, otherwise negative

Medications
Aspirin 81mg, Carvedilol, Lisinopril, Amlodipine, Simvastatin, EPO injections, Alprazolam, Trazodone

Allergies: NKDA

DIAGNOSTIC WORKUP
Physical Exam
Gen: AOx3
CVS: RRR, S1/S2+
Lungs: CTA b/l
Abd: soft, nontender/nondistended, no palpable pulsatile mass
Ext: b/l dp/pt pulses palpable

Laboratory Data
WBC 4.7
H/H 8.2/25.5
Plt 174
Creatinine 1.2
PT 14.8
PTT 41.6 INR 1.2

Triple-phase CT Angiogram of Abdomen/Pelvis

Lumbar arteries and median sacral artery are the feeding vessels.

DIAGNOSIS
Type IIb endoleak of infrarenal abdominal aortic aneurysm endograft

QUESTION SLIDE
1) The most common contributing vessels to a type II endoleak are:
A: Celiac artery and inferior mesenteric artery.

B: Superior mesenteric artery and inferior mesenteric artery.

C: Inferior mesenteric artery and lumbar arteries.

D: Superior mesenteric artery and internal iliac arteries.

CORRECT!
1) The most common contributing vessels to a type II endoleak are:
A: Celiac artery and inferior mesenteric artery.

B: Superior mesenteric artery and inferior mesenteric artery.

C: Inferior mesenteric artery and lumbar arteries.

D: Superior mesenteric artery and internal iliac arteries.

CONTINUE WITH CASE

SORRY, THATS INCORRECT!

1) The most common contributing vessels to a type II endoleak are:
A: Celiac artery and inferior mesenteric artery.

B: Superior mesenteric artery and inferior mesenteric artery.

C: Inferior mesenteric artery and lumbar arteries.

D: Superior mesenteric artery and internal iliac arteries.

CONTINUE WITH CASE

INTERVENTION
CT-guided aortic puncture and vascular sheath placement x2
Translumbar aortogram

Fluoroscopy-guided Onyx and coil embolization of type IIb endoleak

feeding vessels

INTERVENTION (CONT.)
CT-guided aortic puncture and vascular sheath placement x2

INTERVENTION (CONT.)
Translumbar aortogram

INTERVENTION (CONT.)
Fluoroscopy-guided Onyx and coil embolization of type IIb endoleak feeding vessels

INTERVENTION (CONT.)
Fluoroscopy-guided Onyx and coil embolization of type IIb endoleak feeding vessels

QUESTION SLIDE
2) Ethylene vinyl alcohol (EVOH) liquid embolic aka Onyx is sometimes preferred
for endoleak embolization because it has no risk of non-target embolization
compared to cyanoacrylate glue.
A: True
B: False

CORRECT!
2) Ethylene vinyl alcohol (EVOH) liquid embolic aka Onyx is sometimes preferred
for endoleak embolization because it has no risk of non-target embolization
compared to cyanoacrylate glue.
A: True
B: False. Onyx has a real, but uncommon, risk of nontarget embolization minimized
by slow injections and use of the high viscosity form when appropriate.

CONTINUE WITH CASE

SORRY, THATS INCORRECT!

2) Ethylene vinyl alcohol (EVOH) liquid embolic aka Onyx is sometimes preferred
for endoleak embolization because it has no risk of non-target embolization
compared to cyanoacrylate glue.
A: True
B: False. Onyx has a real, but uncommon, risk of nontarget embolization minimized
by slow injections and use of the high viscosity form when appropriate.

CONTINUE WITH CASE

CLINICAL FOLLOW UP
Post-procedure day 1: CT abdomen/pelvis without PO/IV contrast

1-month post-embolization triple-phase CTA is pending

SUMMARY & TEACHING POINTS

Endovascular aortic repair (EVAR) first published by Parodi et al in 1991 in the
Annals of Vascular Surgery
Major complication of EVAR is endoleak: The persistence of blood flow outside
the lumen of the endoluminal graft but within an aneurysm sac Baum et al,
2004

Incidence of endoleak after EVAR is about 33%

Most common is type II ~80%
Risk factors: tortuous anatomy, many branch vessels, ?anticoagulation

Common post-EVAR surveillance: 1 mo, 6 mos, and annually using CT, US, or angio

SUMMARY & TEACHING POINTS

Endoleak classification:
Type I: attachment site leaks
A: proximal
B: distal
C: iliac occluder
Rx: immediate balloons, stents, or
stent-graft extension
Type II: collateral vessel leaks (lumbar
arteries, IMA, or median sacral artery)
A: simple (single vessel)
B: complex (2 or more vessels)
Rx: delayed placement of coils, glue,
EVOH (Onyx)

Type III: graft failure

A: midgraft hole
B: junctional leak or disconnect
C: other (suture holes, etc.)
Rx: immediate covering with stentgraft

Type IV: graft wall porosity

Rx: usually none
Type V: endotension
+/- endoleak
+/- treatment

SUMMARY & TEACHING POINTS

Approach to embolization of type II endoleak
Translumbar via CT (our approach) or fluoroscopy
Transarterial via fluoroscopy
Pre-op IMA coil embolization before EVAR to decrease type II endoleak and sac enlargement

Agents used in embolization of type II endoleak

Platinum coils, N-butyl cyanoacrylate glue, and/or ethylene vinyl alcohol (EVOH aka Onyx)
Onyx (liquid embolic agent) = EVOH dissolved in dimethyl sulfoxide (DMSO)
+ tantalum contrast powder
Initially used

for intracranial aneurysms

Still has risk of non-target embolization but is delivered in slower, more
controlled manner than glue
Khaja et al, 2014 studied Onyx with or without coil/glue/Amplatzer plug after
TEVAR and EVAR with good result

REFERENCES
Baum, Richard A., Jeffrey P. Carpenter, Michael A. Golden, Omaida C. Velazquez, Timothy W. Clark, S. William Stavropoulos,
Constantine Cope, and Ronald M. Fairman. "Treatment of Type 2 Endoleaks after Endovascular Repair of Abdominal Aortic
Aneurysms: Comparison of Transarterial and Translumbar Techniques." Journal of Vascular Surgery 35.1 (2002): 23-29. Mt. Sinai
Library. Web. 18 Dec. 2014.
Baum, Richard A., William Stavropoulos, Ronald M. Fairman, and Jeffrey P. Carpenter. "Endoleak: What Works?" Journal of
Vascular and Interventional Radiology 15.2 (2004): P217-225. Mt. Sinai Library. Web. 18 Dec. 2014.
Guimaraes, Marcelo, and Mathew Wooster. "Onyx (Ethylene-vinyl Alcohol Copolymer) in Peripheral Applications." Seminars in
Interventional Radiology 28.3 (2011): 350-56. Mt. Sinai Library. Web. 18 Dec. 2014.
Khaja, Minhaj S., Auh W. Park, Warren Swee, Avery J. Evans, J. Fritz Angle, Ulku C. Turba, Saher S. Sabri, and Alan H. Matsumoto.
"Treatment of Type II Endoleak Using Onyx with Long-term Imaging Follow-up." Cardiovascular and Interventional Radiology 37
(2014): 613-22. Mt. Sinai Library. Web. 18 Dec. 2014.
Martin, Michael M., Bart L. Dolmatch, Peter D. Fry, and Lindsay S. Machan. "Treatment of Type II Endoleaks with Onyx." Journal of
Vascular and Interventional Radiology 12 (2001): 629-32. Mt. Sinai Library. Web. 18 Dec. 2014.
Ward, Thomas J., Stuart Cohen, Aaron M. Fischman, Edward Kim, Francis S. Nowakowski, Sharif H. Ellozy, Peter L. Faries, Michael
L. Marin, and Robert A. Lookstein. "Preoperative Inferior Mesenteric Artery Embolization before Endovascular Aneurysm Repair:
Decreased Incidence of Type II Endoleak and Aneurysm Sac Enlargement with 24-month Follow-up." Journal of Vascular and
Interventional Radiology 24.1 (2013): 49-55. Mt. Sinai Library. Web. 18 Dec. 2014.