Transcaval endoleak embolization using intravascular ultrasound: A step-by-step guide

Type II endoleaks are common benign complications that occur following endovascular aneurysm repair (EVAR). When traditional transarterial embolization fails in the management of these endoleaks, alternative approaches such as the transcaval approach can be attempted. The transcaval approach can be performed from either right internal jugular or common femoral vein access sites. The technique utilizes intravascular ultrasound or landmark fluoroscopy to visualize direct needle access into the aneurysm sac. Once access is obtained, the source of the endoleak can be embolized with either coils, liquid embolics, or thrombin. The technique is well tolerated by the vast majority of patients. Technical challenges include the need for a capable assistant and approach vectors. Possible complications include iatrogenic type III endoleaks, graft and/or coil pack infections, and persistent or recurrent type II endoleaks. This article will review indications and evaluation of patients for transcaval endoleak embolization, describe the procedure in a step-by-step fashion, and discuss potential technical challenges and complications.