Building an Endoleak Service Line

In this episode, host Dr. Sabeen Dhand interviews interventional radiologist Dr. David Kim about how he treats endoleaks, including how he raised his success rate from 50% to 90% and built a major endoleak referral center.

At the beginning of his career, Dr. Kim made an effort not to compete with other endovascular specialists but to find a complicated vascular problem and focus on embolization that others weren’t doing. Due to the increase in endovascular aneurysm repairs (EVARs), he saw an increasing endoleak case volume and realized he was one of only a few in the area that could treat them. He built relationships with the vascular surgeons and cardiologists and with the help of a scheduling assistant at a hospital and referrals from his Terumo device rep he now has a busy endoleak service.

Dr. Kim sees many variations of endoleaks. A typical type 2 endoleaks is due to retrograde flow from either a lumbar, inferior mesenteric, or median sacral back into the excluded aneurysm sack which causes increased pressure, flow, and sometimes enlargement or rupture after EVAR repair of an abdominal aortic aneurysm (AAA). Type 1 endoleaks are generally repaired by vascular surgery.

Dr. Kim uses a direct stick technique, rather than transarterial. He starts in CT with the patient prone, under general anesthesia. He uses an 18-gauge Hawkins needle with a blunt dissecting tip down to the posterior aspect of the aneurysm sack. He then inserts the sharp stylette to enter the sack. He exchanges the needle for an Amplatz wire which he inserts securely into the lumen to prevent dislodging during transport from CT to the angiosuite. He sutures the sheath with nylon rather than silk. Once in the angiosuite he uses a 4 French Glidecath and starts by doing an aortogram to determine the flow channels. If able to see the inflow, he deploys coils there and then works backward. After deploying Terumo coils, he finishes with Onyx to seal up the gaps. Using more coils and adding Onyx has been a key component in increasing his success rate from 50% to 90%.