Radiation exposure from pre-emptive coil embolization versus secondary interventions for endoleak-induced aneurysm sac growth following endovascular abdominal aortic aneurysm repair

Abstract

Objective

Pre-emptive embolization of the inferior mesenteric artery and lumbar arteries has been shown to reduce aneurysm sac growth and secondary interventions following endovascular aneurysm repair (EVAR). It is unclear if this strategy will increase radiation exposure compared with secondary interventions performed for endoleak-induced sac growth. We examined the cumulative procedural radiation exposure associated with pre-emptive embolization of aneurysm sac branches and compared it with that of secondary interventions.

Methods

A retrospective analysis was performed on patients who underwent EVAR for nonruptured, infrarenal abdominal aortic aneurysms (AAAs) from January 2012 to December 2022, and who were followed up until February 2024. Procedural radiation data was collected using fluoroscopy time (minutes), dose area product (DAP; μGym²), and radiation dose (mGy). Cumulative radiation exposure included pre-emptive embolization, EVAR, and any endovascular secondary interventions for sac growth.

Results

There were 112 patients (90 male; mean age, 72.4 ± 8.3 years; mean AAA diameter, 58.4 ± 12.3 mm) with available radiation data. Pre-emptive embolization was associated with significantly fewer secondary interventions (8/55 [14.5%] pre-emptive embolization only vs 20/57 [35%] no pre-emptive embolization, needed secondary intervention; P = .012). Patients were grouped as follows: Group 0 (G0) no pre-emptive embolization or secondary intervention (n = 37); Group 1 (G1) pre-emptive embolization only (n = 47); Group 2 (G2) secondary intervention only (n = 20); and Group 3 (G3) both pre-emptive embolization and secondary intervention (n = 8). Fluoroscopy time, total DAP, and radiation dose from EVAR did not differ significantly among the four groups. Radiation exposure was significantly higher in those with secondary intervention only (G2: DAP, 110,567 ± 132,296 μGym²) compared with those who were pre-emptively embolized and still needed a secondary intervention (G3: DAP, 71,566 ± 49,592 μGym²; P = .0016). This is because patients with secondary interventions only required more sessions of endovascular procedures compared with those who received pre-emptive embolization and still required secondary interventions (G2: 2.2 vs G3: 1.23 sessions; P < .001). Total radiation exposure was significantly different across groups, with the highest in patients who received secondary interventions only (G2).

Conclusions

Pre-emptive embolization of aneurysm sac branches was associated with less secondary interventions for sac growth post-EVAR. Cumulative radiation exposure in patients who received pre-emptive embolization was significantly less compared with that in patients who underwent secondary interventions for endoleak-induced sac growth. Pre-emptive embolization may mitigate secondary interventions and reduce overall radiation exposure in patients with AAAs being treated with EVAR.