Percutaneous Micro-Robotic Targeting of Type II Endoleaks Post-EVAR

Overview

This report describes a novel micro-robotic, arm-based percutaneous approach for treating persistent type II endoleaks after endovascular aneurysm repair (EVAR) in nine patients. The technique enabled precise targeting of the aneurysm sac in the angio-suite, facilitating successful embolization when conventional endovascular access was not feasible.

Background

Abdominal aortic aneurysms (AAA) are localized dilatations of the abdominal aorta exceeding 3 cm, with EVAR being the standard treatment for large aneurysms. Type II endoleaks, caused by retrograde flow from branch vessels into the aneurysm sac, occur in 9–30% of EVAR patients and may require intervention if sac enlargement exceeds 5 mm. Traditional transarterial embolization may be impossible in some cases, necessitating direct percutaneous puncture, which carries risks due to difficult access. The use of a micro-robotic system in the angio-suite offers a promising alternative for safe and accurate sac targeting.

Data Highlights

Between January 2020 and January 2023, nine patients with persistent and enlarging type II endoleaks post-EVAR underwent percutaneous micro-robotic guided treatment. Pre-procedural imaging included contrast-enhanced CT or MRI for nidus localization. Procedures were performed under general anesthesia using a single-plane C-arm angiography system with robotic targeting. Post-procedure imaging assessed embolization success by comparing pre- and post-treatment perfused endoleak volumes.

Key Findings

• All nine patients had persistent type II endoleaks unsuitable for endovascular transarterial treatment.
• The micro-robotic system enabled precise needle alignment and insertion under live fluoroscopic control, minimizing risk to adjacent structures.
• Successful puncture of the aneurysm sac was confirmed by blood backflow and angiographic visualization of the endoleak.
• Selective embolization of feeding vessels was achieved using micro-coils and liquid embolic agents (Onyx®), effectively occluding inflow.
• Post-procedural imaging demonstrated reduction or elimination of perfused endoleak volume, indicating treatment success.
• The approach was feasible and safe in a tertiary center with stereotactic navigation expertise.

Clinical Implications

The micro-robotic percutaneous approach provides a valuable alternative for treating type II endoleaks when conventional endovascular access is not possible. It allows for precise, minimally invasive targeting of the aneurysm sac under fluoroscopic guidance, potentially reducing procedural risks such as organ injury and bleeding. This technique may expand therapeutic options in complex post-EVAR endoleak management.

Conclusion

Micro-robotic guided percutaneous embolization in the angio-suite is a feasible and effective method for treating persistent type II endoleaks after EVAR, especially when endovascular routes are inaccessible. This approach enhances procedural safety and accuracy, contributing to improved patient outcomes.

References

1. Abdominal Aortic Aneurysms Epidemiology and Management
2. Endovascular Aneurysm Repair and Endoleak Classification
3. Type II Endoleak Incidence and Treatment Strategies
4. Percutaneous Approaches for Endoleak Embolization