Direct Sac Puncture and Liquid Embolization of a Popliteal Artery Aneurysm with Type II Endoleak

Purpose: To explore the various management options for popliteal artery aneurysms (PAAs) and describe various endovascular and extravascular approaches to treat complications secondary to type II endoleaks, specifically direct sac puncture with Onyx liquid embolization (Medtronic).

Materials and Methods: An 80-year-old man with a history of peripheral arterial disease and multifocal arterial aneurysms presents with an expanding left PAA requiring endovascular stent-graft exclusion in 2012. This was complicated by a type II endoleak refractory to several sessions of transarterial geniculate artery embolization in 2018. At this point, direct percutaneous sac puncture and liquid embolization was performed. Preprocedural Doppler ultrasonography visualized a partially thrombosed PAA with arterial vascular waveforms. Under ultrasound guidance, the superior portion of the sac was percutaneously accessed, yielding pulsatile bright red blood. A 3-Fr short sheath and microcatheter system was introduced, and digital subtraction angiography demonstrated regional filling of the sac with delineation of various inflow and outflow vessels. Various consistencies of Onyx liquid embolic were administered into the sac under real-time fluoroscopic guidance.

Results: Immediate postprocedure ultrasonography confirmed absent flow within the sac, and the patient was discharged on the same day without complication. One-month follow-up ultrasonography demonstrated stability of the sac size with extensive thrombosis and absent internal Doppler flow.

Conclusions: Persistent type II endoleaks of the PAA present a challenging clinical dilemma for vascular interventionalists. The development of occult collateral feeding vessels into the aneurysm sac can be technically difficult to treat with traditional endovascular embolization. In patients with PAA complicated by type II endoleaks refractory to standard endovascular treatment, direct sac embolization may be considered.