Midterm evaluation of perigraft arterial sac embolization in endovascular aneurysm repair

Management of clinically significant endoleaks (ELs) remains costly, time-consuming, and morbid. Unresolved ELs can result in rupture and mortality after endovascular aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) has been used to treat ELs diagnosed at the time of EVAR or during surveillance.

A retrospective review of prospectively maintained databases was conducted. The databases were compiled from two institutions between 2006 and 2016. PASE was performed for type I, type II, or type III EL with a thrombin, contrast medium, and Gelfoam (Pfizer, New York, NY) slurry prepared as previously described. PASE was administered either at the time of EVAR (primary) or during surveillance (secondary). Safety end points included nontarget embolization, defined as neurologic or enteric clinical sequelae from lumbar artery or visceral artery embolization, allergic reaction, peripheral embolization, or rupture. Efficacy end points included successful resolution of EL and cessation of aneurysm sac growth on computed tomography (CT) scans with contrast enhancement.

A total of 66 patients included in the study were treated with PASE. Primary PASE was performed in 38 patients (58%) and secondary in 28 (42%). Within the total cohort, the average clinical and CT scan follow-up was 1.7 years (0.1-11.6 years). Four patients required open repair for residual high-pressure ELs (one type IIIB and three type I; 6%). Of the 95% of patients who did not require open conversion, aneurysm growth did not occur during the follow-up period. In the overall cohort, PASE was successful in 88% of type I EL and 73% of patients with type II EL. There was no evidence of recanalization after thrombosis of culprit vessel for EL. No patients suffered nontarget embolization, spinal ischemia, allergic reaction, post-EVAR rupture, or colonic ischemia.

Primary and secondary PASE proved to be a safe, effective, and durable tool in sac management in conjunction with EVAR. Treating ELs during or after EVAR with PASE has minimized the incidence of EL on CT scan and halted aneurysm growth in our cohort. Further studies are needed to confirm the long-term durability of PASE in reducing secondary interventions after EVAR.