Embolization by Direct Puncture with a Transpedicular Approach Using an Isocenter Puncture (ISOP) Method in a Patient with a Type II Endoleak After Endovascular Aortic Repair (EVAR).
BACKGROUND
Endovascular aortic repair (EVAR) requires further intervention in 20-30 % of cases, often due to type II endoleak (T2EL). Management options for T2EL include transarterial embolization, direct puncture (DP), or transcaval embolization. We report the case of an 80-year-old man with T2EL who successfully underwent DP embolization.


METHODS
Embolization by DP was performed with a transpedicular approach using an isocenter puncture (ISOP) method. An isocenter marker (ICM) was placed at a site corresponding to the aneurysm sac on fluoroscopy in two directions (frontal and lateral views). A vertebroplasty needle was inserted tangentially to the ICM under fluoroscopy and advanced to the anterior wall of the vertebral body. A 20 cm-length, 20-G-PTCD needle was inserted through the outer needle of the 13-G needle and advanced to the ICM. Sac embolization using 25 % N-buty-2-cyanoacrylate diluted with Lipiodol was performed. After complete embolization, rotational DA confirmed good filling of the sac with Lipiodol. The outer cannula and 13-G needle were removed and the procedure was completed.


RESULTS
The patient was discharged the next day. Contrast-enhanced computed tomography 1 and 8 months later showed no Lipiodol washout in the aneurysm sac, no endoleak recurrence, and no expansion of the excluded aneurysm.


CONCLUSIONS
DP with a transpedicular approach using ISOP may be useful when translumbar and transabdominal approaches prove difficult.
Department of Radiology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan, yukky.oct.22@gmail.com.
Yukihisa
Y
Ogawa
Shingo
S
Hamaguchi
Hiroshi
H
Nishimaki
Yuri
Y
Kon
Kiyoshi
K
Chiba
Yuka
Y
Sakurai
Kenji
K
Murakami
Yasunori
Y
Arai
Takeshi
T
Miyairi
Yasuo
Y
Nakajima
D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D004621:Embolization, Therapeutic / Q000295:instrumentation / Q000379:methods*; D057867:Endoleak / Q000628:therapy*; D057510:Endovascular Procedures; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000628:therapy*; D011677:Punctures / Q000295:instrumentation / Q000379:methods*; D016896:Treatment Outcome