Radiofrequency guidewire-facilitated recanalization of chronic thoracic central venous occlusions in hemodialysis patients.

PURPOSE: To assess the outcome and safety of radiofrequency (RF) wire recanalization in patients with end-stage renal disease (ESRD) and chronic central venous occlusions (CVO). MATERIALS AND METHODS: A retrospective review of ESRD patients who underwent RF-wire recanalization of symptomatic chronic thoracic CVO from January 2017 to August 2022 yielded 20 patients who underwent 21 procedures. All patients had undergone at least one prior unsuccessful attempt at central venous recanalization using conventional catheter-based techniques. Technical success was defined by the ability to cross the CVO using RF-wire recanalization enabling endovascular treatment. Access circuit patency was evaluated based on follow-up imaging and symptomatic improvement. RESULTS: Radiofrequency wire recanalization was successful in 17/21 procedures (81%) with all patients (100%) reporting resolution of arm ± facial swelling. Three major complications occurred (14%): two hemothoraces and one hemopericardium. Medial stent diameter was 13 mm (range, 9-14 mm). Mean duration of hospital stay was 2 days ± 3 days. Mean procedure time was 158 ± 46 min with a mean fluoroscopy time of 31.7 ± 16.3 min. Primary unassisted patency at 6 and 12 months was 94 ± 6% and 85 ± 10%, respectively. Additional interventions resulted in significantly increased stent graft patency (P = 0.006). CONCLUSION: Radiofrequency wire-enabled recanalization of CVO in symptomatic dialysis patients has a high rate of technical success with resolution of arm and facial swelling and resumed use of the ipsilateral dialysis access. Although a superior safety profile was seen than with needle-based techniques such as sharp recanalization, major complications were not infrequent indicating that this RF-wire procedure should be performed in centers equipped to manage central venous perforations.

Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution's 20-Year Experience.

PURPOSE: To determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS). MATERIALS AND METHODS: A retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions. RESULTS: Technical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups. CONCLUSIONS: In this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation.

Association between End-Stage Renal Disease and Major Adverse Limb Events after Peripheral Vascular Intervention.

PURPOSE: To examine the effect of end-stage renal disease (ESRD) on the likelihood of major adverse limb events (MALEs) in patients with Rutherford Category 4-6 critical limb ischemia (CLI) who underwent percutaneous vascular intervention (PVI). MATERIALS AND METHODS: Two contemporaneous cohorts of patients who underwent PVI for symptomatic CLI from 2012 to 2022, differing in ESRD status, were matched using propensity score methods. This database identified 628 patients who underwent 1,297 lower extremity revascularization procedures; propensity score matching yielded 147 patients (180 limbs, 90 limbs in each group). Kaplan-Meier and Cox proportional hazard analyses were used to assess the effect of ESRD status on MALEs, stratified into major amputation (further stratified into above-knee amputation and below-knee amputation [BKA]) and reintervention (PVI or bypass). RESULTS: After PVI, 31.3% of patients in the matched cohorts experienced a MALE (45.7% ESRD vs 18.2% non-ESRD), and 15.6% experienced a major amputation (27.1% ESRD vs 5.2% non-ESRD). Cox proportional hazards analysis revealed that ESRD was an independent predictor of MALE (hazard ratio [HR], 3.15; 95% CI, 1.58-6.29; P = .001), major amputation (HR, 7.00; 95% CI, 2.06-23.79; P = .002), and BKA (HR, 7.56; 95% CI, 1.71-33.50; P = .008). CONCLUSIONS: ESRD is strongly predictive of MALE and major amputation risk, specifically BKA, in patients undergoing PVI for Rutherford Category 4-6 CLI. These patients warrant closer follow-up, and new methods may become necessary to predict and further reduce their amputation risk.

Dialysis Access-Associated Steal Syndrome and Management.

Dialysis-associated steal syndrome (DASS) occurs in 1-8% of hemodialysis patients with arteriovenous (AV) access. Major risk factors include use of the brachial artery for access creation, female sex, diabetes, and age > 60 years. DASS carries severe patient morbidity including tissue or limb loss if not recognized and managed promptly, as well as increased mortality. Diagnosis of DASS requires a directed history and physical exam supported by non-invasive testing. Prior to definitive therapy, detailed arteriography, fistulography, and flow measurements are performed to delineate underlying etiologies and guide management. To optimize success, DASS treatment should be individualized according to access location, underlying vascular disease, flow dynamics, and provider expertise. Possible causes of DASS include extremity inflow or outflow arterial occlusive disease, high AV access flow rate, and reversal of distal extremity arterial blood flow; DASS may also exist without any of the prior features. Depending on the DASS etiology, various endovascular and/or surgical interventions should be considered. Regardless, in the majority of patients presenting with DASS, access preservation can be achieved.

Endovascular creation of hemodialysis arteriovenous fistulae: the current status and future perspective-a literature review.

Background and Objective: End-stage renal disease (ESRD) is increasingly prevalent among Americans. Traditionally, the gold standard of dialysis fistulae creation is surgical arteriovenous fistulae (AVF), which is preferred over central venous catheter (CVC) and arteriovenous graft (AVG). However, it is associated with many challenges, particularly its high primary failure rate, which is partially attributed to neointimal hyperplasia. Endovascular creation of arteriovenous fistulae (endoAVF) is a recently emerging method, and is thought to circumvent many of the surgical challenges. It is theorized to reduce the peri-operative trauma to the vessel, thus reducing the amount of neointimal hyperplasia. In this article, we aim to review the current status and future perspectives of endoAVF. Methods: An electronic search was performed on MEDLINE and Embase to identify relevant articles from 2015 to 2021. Key Content and Findings: The initial trial data has been promising, resulting in the increased adoption of endoAVF devices in clinical practice. Further, short- and mid-term data has shown that endoAVF has been associated with good maturation rate, re-intervention rate, primary and secondary patency rates. In comparison to historical surgical data, endoAVF has been shown to be comparable in certain aspects. Lastly, endoAVF has been used in an increasing range of clinical applications, including wrist AVF and two-stage transposition procedure. Conclusions: Although current data has been promising, endoAVF is associated with a host of unique challenges, and the current data has mostly been derived from selective patient population. Further studies are required to further assess its usefulness and its role in the dialysis care algorithm.

Outcome and technical evolution of type 2 endoleak embolization with ethylene-vinyl-alcohol copolymer.

PURPOSE: This study aims to evaluate the safety and efficacy of novel approaches to type 2 endoleak access for the purpose of embolization using ethylene-vinyl-alcohol copolymer (EVOH) in patients with abdominal aortic aneurysm (AAA) sac expansion post endovascular abdominal aortic repair (EVAR). METHODS: A retrospective review of 43 consecutive patients (mean age = 80.2 ± 6.7 years) who underwent 52 embolization procedures for type 2 endoleaks using EVOH was performed at a single institution. Catheterization of the endoleaks was achieved using the transarterial (TA) and direct translumbar approaches (DTL), in addition to the novel direct transabdominal (DTA) and perigraft (PG) approaches. Endpoints included technical success of endoleak catheterization, technical success of endoleak embolization, endoleak persistence, endoleak recurrence, AAA sac area change, and adverse events. RESULTS: The TA, DTL, DTA, and PG approaches were used 25, 2, 14, and 19 times respectively, including nine procedures where a combination of approaches was used. The technical success rate of endoleak embolization was 98%. Five patients developed recurrent type 2 endoleaks, while five patients developed a type 1 endoleak. The persistent endoleak rate at a mean initial follow-up of 3 months was 34%. At a mean follow-up of 18 months, 58% of patients demonstrated absence of an endoleak, and 71% showed freedom from AAA sac enlargement. No major adverse events were recorded. CONCLUSION: The DTA and PG approaches were safe and effective in this cohort of patients undergoing embolization of type 2 endoleaks with EVOH.

Diagnostic yield of computed tomographic pulmonary angiography for suspected pulmonary embolism varies across settings within a community-based health system.

PURPOSE: The diagnostic yield of computed tomographic pulmonary angiography (CTPA) for pulmonary embolism varies in the literature, and very little data is available regarding community-based systems. This study evaluates the yield of CTPA for pulmonary embolism across a variety of patient care settings in a community-based healthcare system, providing relevant benchmarks for potential quality improvement efforts. METHODS: This retrospective study included data collected from three sites within a single community-based healthcare system, including a tertiary care level 1 trauma center, an urban community hospital, and a suburban free-standing emergency department. CTPAs were identified by Current Procedural Terminology codes, and diagnoses of pulmonary embolism were identified via International Classification of Diseases codes. A total of 7850 CTPA studies met criteria for inclusion between January 1, 2012, and October 8, 2014. RESULTS: Pulmonary embolism was found in 884 (11.3%) of the studies performed. Outpatients had a lower yield of pulmonary embolism (3.8%, p < 0.001) compared with inpatients (14.1%) and emergency department patients (10.7%, p < 0.001). Patients with diagnoses of deep vein thrombosis or neoplasm had increased incidence of pulmonary embolism when compared with patients without these diagnoses (p < 0.001 for both). CONCLUSION: The overall yield of CTPA for pulmonary embolism in this community-based system was similar to that at academic centers. The yield was significantly lower in the outpatient setting compared with studies originating in the emergency department or inpatient setting.

Safety and Efficacy of Arterial Closure Devices Following Antegrade Femoral Access: A Case-Control Study.

PURPOSE: Vascular closure device (VCD) use following antegrade femoral access may present unique challenges relative to retrograde access. We retrospectively compared safety and efficacy of these devices between antegrade and retrograde patient cohorts undergoing percutaneous intervention. MATERIALS AND METHODS: Over a 5-year period, a consecutive series of 107 limbs in 84 patients underwent VCD arteriotomy closure following percutaneous revascularization using an antegrade approach (VCD-A). Device deployment success rates, time to ambulation, and complication rates were compared to a contemporaneous control group of 401 limbs in 305 patients who underwent closure following retrograde access (VCD-R) during revascularization or embolization procedures. RESULTS: Closure was attempted in VCD-A using 53 StarClose, 35 Perclose, and 19 Angio-Seal devices. Hemostasis (without supplemental manual compression) was achieved in 86/107 (80.4%) limbs. Closure was attempted in VCD-R using 215 StarClose, 119 Perclose, and 67 Angio-Seal devices with hemostasis in 357/401 (89.0%) limbs. Device deployment failure occurred in 7/107 (6.5%) of VCD-A and 20/401 (5.0%) of VCD-R (P = .52), independent of specific device type. Femoral pseudoaneurysm developed in 1/107 and 1/401 of VCD-A and VCD-R (P = .31), and minor hematoma developed in 3/107 and 8/401 of the VCD-A and VCD-R (P = .61). Mean time to ambulation was 204.1 minutes in VCD-A and 204.8 minutes in VCD-R (P = .97). CONCLUSION: Antegrade femoral closure was associated with high rates of technical success and low complications, similar to retrograde closure. Time to ambulation was the same in both groups despite higher heparin doses in the antegrade patients.

Diagnosis and Treatment of Nonmaturing Fistulae for Hemodialysis Access via Transradial Approach: A Case-Control Study.

PURPOSE: To compare outcomes of transradial access for endovascular treatment of nonmaturing hemodialysis fistulae compared to brachial arteriography followed by unidirectional or bidirectional fistula access for intervention. MATERIALS AND METHODS: In this institutional review board-approved, retrospective, case-control study, 56 consecutive patients with nonmaturing arteriovenous fistulae underwent percutaneous intervention between 2015 and 2018. The transradial group (n = 28) underwent radial artery access for diagnostic fistulography and intervention. The control group (n = 28) underwent retrograde brachial artery access for fistulography followed by unidirectional/bidirectional fistula access for intervention. Both groups had similar demographics, fistula characteristics, and stenosis locations. RESULTS: Fewer punctures were required in the transradial group compared to controls (1.2 vs 2.4, P < .0001), and procedure time was shorter (64.9 vs 91.3 minutes, P = .0016). Anatomic, technical, and clinical success rates trended higher in the transradial group compared to controls (93% vs 86%, 96% vs 89%, and 82% vs 64%, respectively). Nonmaturation resulting in fistula abandonment was lower in the transradial group (3.7% vs 25%, P = .025). Primary unassisted patency at 3, 6, and 12 months was 77.1% ± 8.2%, 73.1% ± 8.7%, and 53.3% ± 10.6% in the transradial group, respectively, and 63.0% ± 9.3%, 55.6% ± 9.6%, and 48.1% ± 9.6% in the control group, respectively (P = .76). Primary assisted patency at 12 months was 92.3% ± 5.3% in the transradial group compared to 61.8% ± 9.6% at 12 months in the control group (P = .021). No major complications occurred. Minor complications were lower in the transradial group than in the control group (14% vs 39%, P = .068). CONCLUSIONS: Treatment of nonmaturing fistulae via a transradial approach was safe, improved midterm patency, and was associated with lower rates of fistula abandonment.

Deep Learning Based on MR Imaging for Predicting Outcome of Uterine Fibroid Embolization.

PURPOSE: To develop and validate a deep learning model based on routine magnetic resonance (MR) imaging obtained before uterine fibroid embolization to predict procedure outcome. MATERIALS AND METHODS: Clinical data were collected on patients treated with uterine fibroid embolization at the Hospital of the University of Pennsylvania from 2007 to 2018. Fibroids for each patient were manually segmented by an abdominal radiologist on a T1-weighted contrast-enhanced (T1C) sequence and a T2-weighted sequence of MR imaging obtained before and after embolization. A residual convolutional neural network (ResNet) model to predict clinical outcome was trained using MR imaging obtained before the procedure. RESULTS: Inclusion criteria were met by 727 fibroids in 409 patients. At clinical follow-up, 85.6% (n = 350) of 409 patients (590 of 727 fibroids; 81.1%) experienced symptom resolution or improvement, and 14.4% (n = 59) of 409 patients (137 of 727 fibroids; 18.9%) had no improvement or worsening symptoms. The T1C trained model achieved a test accuracy of 0.847 (95% confidence interval [CI], 0.745-0.914), sensitivity of 0.932 (95% CI, 0.833-0.978), and specificity of 0.462 (95% CI, 0.232-0.709). In comparison, the average of 4 radiologists achieved a test accuracy of 0.722 (95% CI, 0.609-0.813), sensitivity of 0.852 (95% CI, 0.737-0.923), and specificity of 0.135 (95% CI, 0.021-0.415). CONCLUSIONS: This study demonstrates that deep learning based on a ResNet model achieves good accuracy in predicting outcome of uterine fibroid embolization. If further validated, the model may help clinicians better identify patients who can most benefit from this therapy and aid clinical decision making.

Radial Access for Neurovascular Procedures.

Radial access is increasingly being considered in neurovascular procedures after becoming the standard access route in percutaneous cardiovascular interventions. Current barriers include a lack of dedicated equipment for radial to neurovascular target vessels, lack of training for physicians and fellows, and physician bias toward femoral access secondary to greater experience and familiarity. Radial access has been proven to be safer and the preferred access route by most patients. These two factors make radial access inevitability when the aforementioned barriers are overcome. The purpose of this brief article is to highlight some important considerations of radial access specific to the neurovasculature.

Nonfemoral Arterial Hemostasis Following Percutaneous Intervention Using a Focused Compression Device.

PURPOSE: Upper extremity and tibiopedal arterial access are increasingly used during endovascular therapies. Balloon compression hemostasis devices in these anatomic locations have been described, but most utilize a compression surface extending well beyond the puncture site. We report single-center experience with an arterial puncture-focused compression device following upper extremity and tibiopedal access. PATIENTS AND METHODS: A series of 249 focused compression hemostasis devices (VasoStat, Forge Medical, Bethlehem, Pennsylvania, USA) were used in 209 patients following lower extremity (n = 63) and upper extremity (n = 186; radial: 90%) arterial access procedures using 4-7 French sheaths. Demographic, operative, and follow-up data were collected. Logistic regression was used to evaluate potential association between patient/operative variables and time to hemostasis. RESULTS: Primary hemostasis was achieved in 97.2% (242/249) following sheath removal; in 7 cases (2.8%) puncture site oozing occurred after initial device removal and required reapplication. Secondary hemostasis was 100% (249/249). Seven complications (2.8%) were recorded: 5 minor hematomas (2%) and 2 transient access artery occlusions (0.8%). Mean time to hemostasis enabling device removal was 55 ± 28 min. Elevated body mass index (BMI) was not associated with increased time to hemostasis (p = 0.31). Accessed artery, sheath size, and heparin dose were also not associated with time to hemostasis (p = 0.64; p = 0.74; p = 0.75, respectively). CONCLUSIONS: The focused compression hemostasis device enabled rapid hemostasis with a low complication rate. Time to hemostasis was independent of BMI, access site, sheath size, or heparin dose.

Inferior Vena Cava Reconstruction in Symptomatic Patients Using Palmaz Stents: A Retrospective Single-Center Experience.

BACKGROUND: The use of stents for treating central venous occlusion is well described. Limited evidence exists related to Palmaz balloon-expandable stent use in inferior vena cava (IVC) reconstruction. We analyzed patency and complication rates after IVC reconstruction using Palmaz stents. METHODS: From 2002 to 2019, 37 patients (mean age: 51 year) underwent IVC reconstruction with 68 Palmaz stents. Indications were symptomatic chronic venous obstruction in the infrarenal (n = 25) and intrahepatic (n = 12) IVC. Demographic, operative, and imaging data were evaluated. Clinical data, abdominal CT, and/or duplex ultrasound were used to determine patency at follow-up. RESULTS: Restoration of caval patency was achieved in all patients, with complications in 2/37 (5.4%) patients (thrombus formation within the stent; stent embolization eight days after placement). Follow-up data were available for 27 patients. Primary patency was maintained through last follow-up in 19/27 (70%) patients (mean: 1.1 year), with successful stent redilation performed in 6 patients. Mean duration of primary-assisted patency (n = 5) was 1.2 year. Late lumen loss was (n = 13) was 40% during a mean time to follow-up of 2.0 years. Primary patency in patients with occlusion secondary to malignancy was 109 day (range: 1 day-1.0 year), whereas primary patency in patients with occlusion from other etiologies was 1.1 year (range: 2 day-5.9 year). The Kaplan-Meier analysis demonstrated primary and primary-assisted patency of 66% and 84%, respectively, at 24 and 48 months. CONCLUSIONS: Palmaz balloon-expandable stents for IVC reconstruction is feasible and effective for symptomatic IVC occlusion. Risk of stent migration was low.

Tips for pedal access: technical evolution and review.

Pedal access has become an indispensable technique for endovascular therapy of complex lower extremity peripheral vascular disease. From an option as a single access in a patient lacking traditional access approaches to a critical maneuver in combined antegrade-retrograde approaches during the treatment of complex chronic total occlusions, pedal access is an essential tool for any endovascular physician treating peripheral arterial disease. Anticipatory planning is critical in the successful utilization of pedal access. The appropriate tibiopedal vessel should be chosen and combined with the ideal access technique. Knowledge of the current medical devices available for pedal access and post-procedural hemostasis is key and can ease the learning curve. We present the evolution of pedal access with a review of the literature and technical tips to incorporate into everyday practice.

Comparison of Ultrasound-Accelerated versus Pigtail Catheter-Directed Thrombolysis for the Treatment of Acute Massive and Submassive Pulmonary Embolism.

PURPOSE: To compare the technical and clinical effectiveness of ultrasound-accelerated endovascular thrombolysis (USAT) versus pigtail catheter-directed thrombolysis (PCDT) for the treatment of acute pulmonary embolism (PE). MATERIALS AND METHODS: A single-center retrospective study of patients treated with USAT or PCDT for acute massive or submassive PE between January 2010 and December 2016 was performed by reviewing electronic medical records. Sixty treatments were reviewed (mean patient age, 56.7 y ± 14.6), including 52 cases of submassive PE (21 treated with USAT, 31 with PCDT) and 8 cases of massive PE (3 treated with USAT, 5 with PCDT). Endpoints included pulmonary artery pressure (PAP), Miller PE severity index, tissue plasminogen activator (TPA) dose, infusion duration, procedural variables, and complications. RESULTS: Demographics, PE severity, and right:left ventricular diameter ratios were similar between groups. USAT and PCDT significantly reduced mean PAP (reductions of 7.4 mm Hg [P = .002] and 8.2 mm Hg [P < .001], respectively) and Miller index scores (reductions of 45.8% [P < .001] and 53% [P < .001], respectively) with similar effectiveness (P = .47 and P = .15, respectively). Procedure (P < .001) and fluoroscopy (P = .001) times were significantly longer in the USAT group. The USAT group underwent fewer sessions (2.2 ± 0.6 vs 2.4 ± 0.6; P = .17) with shorter infusion times (23.9 h ± 8.8 vs 30.4 h ± 12.6; P = .065) and a lower total dose of TPA (27.1 mg ± 11.3 vs 30.4 mg ± 12.6; P = .075) compared with the PCDT group, but the differences were not significant. Complications (P = .07) and 30-day mortality rates (P = .56) were not significantly different between groups. CONCLUSIONS: USAT and PCDT demonstrated comparable effectiveness and safety in the treatment of patients with acute PE.

Patient Preference for Transradial Access over Transfemoral Access for Cerebrovascular Procedures.

PURPOSE: Shared decision-making, when physicians and patients collaborate and agree on health care decisions, is a key tenant of patient-centered care. Choice of access site for neurovascular procedures is rarely a shared decision point between physicians and patients. We present our initial evaluation of patient preference for radial over femoral access for cerebrovascular procedures. MATERIALS AND METHODS: IRB approved single-center, prospective, and consecutive survey of all patients undergoing transradial access for cerebrovascular imaging and intervention. Primary inclusion criteria were patients who had previously undergone a transfemoral access procedure and chose to have their second procedure via a transradial approach. All patients underwent pre-procedural neurologic and extremity exams (including Barbeau tests for radial access suitability prior to radial access), post-procedural neurological evaluation and radial access assessment post-procedure, and complete neurological and radial access-site evaluation in the neurointerventional outpatient clinic 1-2 week post-procedure. RESULTS: Twenty five consecutive patients who underwent radial access cerebrovascular procedures after previous femoral access cerebrovascular procedures (16 diagnostic angiograms and 9 interventional procedures) were included. No major complications (including hematomas, infection, or delayed radial artery occlusion) were encountered during the immediate post-procedurral period or on outpatient follow-up (average 8 days). On immediate post-procedural examination, 16% had mild bruising and 24% had mild pain at the radial access site. Of the 25 patients included in this study, 24 strongly preferred radial access over femoral access and reported that, if they needed another procedure, they would prefer radial access. CONCLUSION: There was nearly unanimous patient preference for radial over femoral access for cerebrovascular procedures in this single-center prospective analysis. There were no major complications and no incidences of delayed radial occlusion. In the current age of value-based and patient-centered medicine, the radial approach should be considered for nearly all neurovascular procedures.

Transcatheter Embolization of Type I Endoleaks Associated With Endovascular Abdominal Aortic Aneurysm Repair Using Ethylene Vinyl Alcohol Copolymer.

PURPOSE: To evaluate the feasibility, safety, and outcome of transcatheter embolization using ethylene vinyl alcohol copolymer (EVOH) of type I endoleaks associated with endovascular abdominal aortic aneurysm repair. PATIENT POPULATION AND METHODS: Retrospective chart review was performed to identify 8 consecutive patients who had undergone EVOH embolization for type I endoleaks between 2012 and 2015. The primary approach used to access the endoleak was the perigraft technique, where the endoleak itself is catheterized at the anastomotic site. RESULTS: Six type Ia and 2 type Ib endoleaks were treated. In 2 patients, a direct transabdominal approach was used to access the endoleak because it was inaccessible via the perigraft approach. Coils were used in addition to EVOH in 5 cases. Residual endoleak was noted in 1 case, whereas 2 patients developed a recurrent type I endoleak during follow-up. No EVOH complications were observed. The 5 remaining patients demonstrated freedom from endoleak and reintervention at a mean follow-up of 6.9 months. CONCLUSION: Type I endoleaks can be safely and effectively treated by embolotherapy with EVOH. Larger endoleaks resulting from grossly undersized endografts appear to be unsuitable for EVOH embolization.