Novel use of intracardiac echocardiography (ICE) catheter in treatment of Type II endoleaks via transcaval approach

Abstract

Introduction: The management of type II endoleak after EVAR continues to evolve. Most literature recommends intervention if aneurysm sac expansion is greater than 5 mm on surveillance imaging. Transcaval access has recently emerged as an effective technique to access the excluded aneurysm sac for endoleak embolization. One limitation of this approach may be direct visualization and cannulation of endoleak cavities within a large aneurysm sac as standard intravascular ultrasound (IVUS) has depth limitations. We present a series of patients in which an Intracardiac Echocardiography (ICE) catheter was used to assist in type II endoleak cavity cannulation, embolization, and confirmation of cessation of flow. Methods: From 2021 – 2022, patients who underwent transcaval embolization of type II endoleak after EVAR were included in our study. All patients were noted to have persistent endoleak with aneurysm sac expansion and failure or inability to perform sac endoleak embolization via conventional methods (transmesenteric, translumbar).ICE catheter was advanced into the IVC via the left common femoral vein. Real-time intra-sac ultrasound was performed via the ICE catheter and the radiopaque tip of the catheter was positioned directly over the endoleak cavity. The radio-opaque tip thus served as a marker for the point of sac entry. A TIPS catheter via the right common femoral vein was used to achieve transcaval access into the excluded aneurysm sac.Embolization was performed using coils or Onyx liquid embolic system (LES), at the discretion of the operating surgeon. Procedural success was defined by cessation of flow in endoleak cavity angiographically, via ICE catheter, and on post-op CT imaging. Results: A total of three patients had endoleaks treated using ICE catheter-assisted transcaval access from 2021 – 2022. Average patient age was 78 years old, average aneurysm sac size at the time of transcaval embolization was 6.75 cm, and average aneurysm sac growth following initial EVAR was 0.45 cm. The average fluoroscopy time for each procedure was 16.8 min, total radiation dose was 1010.06 mGy, and contrast used was 25 mL. Average EBL for the procedure was 7 mL. All procedures were performed in the outpatient setting and patients were discharged home the same day. There were no major adverse events (MAEs) within the first 30-days post-procedure.All three patients had successful embolization of the endoleak cavity, verified by both ICE catheter intra-procedurally and on post-op imaging. Aneurysm sac size was noted to be stable in one patient post-procedurally and was noted to be decreasing in size in two patients. Average patient follow-up time was approximately two weeks after endoleak embolization. Conclusion: The novel use of the ICE catheter allows for: (1) direct visualization of the endoleak cavity prior to transcaval access and (2) confirmation of cessation of blood flow into the sac at the termination of the procedure. The procedure proved to be safe for all three cases described, with the endpoint of endoleak embolization achieved without any ill-effects to the patients. Further study is warranted in the utility of this device in performing transcaval embolization procedures.

Keywords

• Intracardiac Echocardiography catheter
• Type II endoleak
• Transcaval embolization