Giles Kristina A, Fillinger Mark F, De Martino Randall R, Hoel Andrew W, Powell Richard J, Walsh Daniel B
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
J Vasc Surg. 2015 May;61(5):1129-36. doi: 10.1016/j.jvs.2014.12.002.
Management of type II endoleaks after endovascular aneurysm repair can be problematic. This study reports our experience with a relatively novel strategy to treat this complication, transcaval coil embolization (TCCE) of the aneurysm sac.
We reviewed 29 consecutive patients undergoing TCCE from 2010 to 2013. Demographics, operative details, and outcomes were assessed.
Since 2006, 29 TCCEs have been performed at our institution in 26 patients for sac expansion from type II endoleaks. Patients were male (83%) and former or current smokers (88%), with an average age of 78 ± 7.1 years. TCCE was performed a mean of 4.2 ± 4 years after initial endovascular aneurysm repair. Endoleaks resulted in a mean sac growth of 1.2 ± 1 cm in diameter and 37% ± 32% by volume. Forty-six percent had prior procedures (5 translumbar, 3 transarterial, 3 transcaval, 1 aortic cuff, and 1 iliac limb extension). Two patients had no flow identified in the aneurysm sac after puncture was successful, and one was found to have a hygroma rather than arterial flow. An additional two patients had ultimate embolization from sac access between the endograft iliac limb and arterial wall after transcaval puncture failed, for a 90% procedural success (83% for transcaval technical success). Mean fluoroscopy time was 27 ± 13 minutes with 29 ± 21 mL of contrast material used and a median of 10 coils per case. Additional adjuncts included thrombin injection (17%), intravascular ultrasound (14%), sac pressure measurements (28%), and on-table integrated computed tomography (17%). Median length of stay was 1 day (range, 0-5 days). There were no procedural adverse events. Reintervention was required in five cases (three repeated TCCEs, two graft relinings). One-year freedom from reintervention was 95%. At a mean 16.5 months of follow-up, 70% experienced no further endoleak and had stable or decreasing sac diameters. There have been no ruptures during follow-up.
In this series, TCCE for treatment of aneurysm enlargement due to type II endoleaks was safe and relatively effective despite prior failed interventions in nearly half of the cases. TCCE is a useful alternative in cases in which the anatomy makes other approaches difficult or impossible.
血管内动脉瘤修复术后Ⅱ型内漏的处理可能存在问题。本研究报告了我们采用一种相对新颖的策略治疗这种并发症——经腔静脉线圈栓塞术（TCCE）治疗动脉瘤囊的经验。
我们回顾了2010年至2013年连续接受TCCE的29例患者。评估了患者的人口统计学资料、手术细节和治疗结果。
自2006年以来，我们机构对26例患者进行了29次TCCE，用于治疗因Ⅱ型内漏导致的动脉瘤囊扩张。患者以男性为主（83%），既往或目前吸烟者占88%，平均年龄为78±7.1岁。TCCE在初次血管内动脉瘤修复术后平均4.2±4年进行。内漏导致动脉瘤囊直径平均增大1.2±1 cm，体积增大37%±32%。46%的患者曾接受过其他手术（5例经腰动脉、3例经动脉、3例经腔静脉、1例主动脉袖带修补术和1例髂支延长术）。2例患者穿刺成功后动脉瘤囊内未发现血流，1例发现为黏液瘤而非动脉血流。另外2例患者经腔静脉穿刺失败后，最终通过在血管内移植物髂支与动脉壁之间的囊腔通路进行栓塞，手术成功率为90%（经腔静脉技术成功率为83%）。平均透视时间为27±13分钟，使用造影剂29±21 mL，每例患者平均使用10个线圈。其他辅助手段包括注射凝血酶（17%）、血管内超声（14%）、囊腔压力测量（28%）和术中联合计算机断层扫描（17%）。中位住院时间为1天（范围0 - 5天）。无手术相关不良事件。5例患者需要再次干预（3例重复TCCE，2例移植物内衬）。1年无再次干预的比例为95%。平均随访16.5个月时，70%的患者未出现进一步内漏，动脉瘤囊直径稳定或缩小。随访期间无动脉瘤破裂发生。
在本系列研究中，尽管近一半病例此前干预失败，但TCCE治疗因Ⅱ型内漏导致的动脉瘤增大是安全且相对有效的。对于解剖结构使其他方法难以实施或无法实施的病例，TCCE是一种有用的替代方法。
