Neutrophil-lymphocyte ratio is a simple and novel biomarker for prediction of survival after radioembolization for metastatic colorectal cancer.

PURPOSE: Previous studies have reported that an elevated preoperative Neutrophil-Lymphocyte Ratio (NLR) is associated with poor prognosis in patients with various solid tumors including colorectal cancer (CRC). Here, we examine whether NLR predicts survival in patients with unresectable CRC metastases undergoing hepatic radioembolization. METHODS: A retrospective review of 104 consecutive patients with unresectable metastatic CRC who were treated with radioembolization after failing first and second-line chemotherapy. RESULTS: Between 2002 and 2012, the median NLR for all patients was 4.6. Using receiver operating curve analysis, there was no difference between using an NLR cut-off of 4.6 or 5. Forty-eight patients had a high NLR of ≥5 and 56 patients had an NLR of <5. Patients in both groups had similar previous extensive chemotherapy and liver-directed interventions. The median survival of patients with high NLR was 5.6 months (range 4.9-7.9 months) compared with 10.6 months (range 8.3-17.0 months) for patients with low NLR; a significant difference was found in overall survival (log-rank test; p = 0.001). Other factors associated with risk of death were extrahepatic spread of disease, presence of pulmonary nodules, previous liver-targeted intervention, and radiographic response. On multivariate analysis, high NLR, progressive radiographic response, and presence of extrahepatic disease remained independently associated with increased risk of death. CONCLUSIONS: NLR is a simply attainable, inexpensive, and useful biomarker to predict outcome in patients with metastatic colorectal cancer receiving radioembolization.

The Prognostic Role of Neutrophil-to-Lymphocyte Ratio in Patients with Unresectable Hepatocellular Carcinoma Treated with Radioembolization.

PURPOSE: To assess the prognostic value of neutrophil-to-lymphocyte ratio (NLR) in patients with unresectable intermediate- or advanced-stage hepatocellular carcinoma (HCC) treated with yttrium-90 radioembolization (RE). MATERIALS AND METHODS: Retrospective chart review was performed for 176 patients with intermediate- or advanced-stage HCC treated with RE between August 2000 and November 2012. The appropriate NLR cutoff was determined by receiver operating characteristic curves. Demographic, clinical, radiographic, and pathologic parameters were compared between patients with a normal NLR (< 5) and those with an elevated NLR (≥ 5) before RE. Barcelona Clinic Liver Cancer (BCLC) stage-stratified univariate and multivariate analyses were conducted to determine variables associated with overall survival. RESULTS: Under univariate analyses, patients with a normal NLR were found to have longer survival than individuals with a high NLR in intermediate/advanced-disease and advanced-disease cohorts. A multivariate Cox proportional-hazards model in the advanced-disease group confirmed that elevated NLR, high α-fetoprotein level, and low albumin level were independent predictors of worse survival. CONCLUSIONS: This study provides stage-dependent evidence for the prognostic role of NLR in the radioembolized HCC cohort. Patients with BCLC stage C disease with elevated NLR may not derive benefit from RE, and other intervening modalities should be explored in this subpopulation.

Retained surgical stents as a cause of biliary obstruction in pediatric liver transplants.

BACKGROUND: Small-caliber plastic stents are sometimes placed across the hepaticojejunostomy in liver transplant recipients at the time of biliary reconstruction. These stents usually pass spontaneously, but they can be retained and, rarely, this may cause biliary obstruction. OBJECTIVE: The purpose of this paper is twofold: to describe the appearance of biliary tract obstruction caused by retained surgical stents in pediatric liver transplants, and to report how these stents can be removed using interventional radiology techniques. MATERIALS AND METHODS: Three pediatric patients presenting with biochemical and imaging evidence of biliary obstruction were encountered over a 6-month period. At percutaneous cholangiography all patients were found to have retained surgical stents which appeared to be causing biliary tract obstruction. Percutaneous snaring of the stents was undertaken. RESULTS: All stents were successfully removed using interventional radiology techniques, and follow-up showed no evidence of recurrent obstruction. CONCLUSION: Surgical stents in children undergoing hepaticojejunostomy may be retained and cause biliary obstruction. Radiologists involved with imaging these patients should be aware of this potential cause of biliary obstruction. This complication is amenable to interventional radiology techniques with good long-term results. There is no easy endoscopic or surgical treatment option in these patients.

A case-based approach to common embolization agents used in vascular interventional radiology.

OBJECTIVE: The objective of this article is to familiarize the reader with the most commonly used embolic agents in interventional radiology and discuss an approach for selecting among the different embolic agents. This article reviews their properties and uses a case-based approach to explain how to select one. CONCLUSION: A wide variety of embolic agents are available. Familiarity with the available embolic agents and selection of the most appropriate embolic agent is critical in interventional radiology to achieve optimum therapeutic response and avoid undesired, potentially disastrous complications such as nontarget embolization.

Survival and tolerability of liver radioembolization: a comparison of elderly and younger patients with metastatic colorectal cancer.

AIM: To evaluate the outcomes among elderly (≥70 years) and younger patients (<70 years) with liver-dominant metastatic colorectal cancer (mCRC) who received radioembolization (RE) as salvage therapy. METHODS: A retrospective review of 107 consecutive patients with unresectable mCRC treated with RE after failing first- and second-line chemotherapy. RESULTS: From 2002 to 2012, 44 elderly and 63 younger (<70 years) patients received RE. Patients had similar previous extensive chemotherapy and liver-directed interventions. Using modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria, either a stable or a partial radiographical response was seen in 65.8% of the younger compared with 76.5% of the elderly patients. RE was equally well tolerated in both groups and common procedure-related adverse events were predominantly grade 1-2 and of short duration. No significant difference was found with regard to overall median survival between younger [8.4 months; 95% confidence interval (CI) = 6.2-10.6] or elderly patients (8.2 months; 95% CI = 5.9-10.5, P = 0.667). The presence of extrahepatic disease at the time of RE was associated with a significantly worse median survival in both groups. CONCLUSION: Radioembolization appears to be as well tolerated and effective for the elderly as it is for younger patients with mCRC. Age alone should not be a discriminating factor for the use of radioembolization in the management of mCRC patients.

Yttrium-90 radioembolization as a bridge to liver transplantation: a single-institution experience.

PURPOSE: To evaluate our experience with the use of yttrium-90 ((90)Y) radioembolization in maintaining potential candidacy and, in some instances, downstaging hepatocellular carcinoma (HCC) that does not meet Milan criteria for liver transplantation. MATERIALS AND METHODS: A retrospective review of 20 consecutive patients with HCC who were listed to receive a liver transplant and were treated with (90)Y radioembolization as a sole modality for locoregional "bridge" therapy was performed. Demographics, radiographic and pathologic response, survival, and recurrences were examined. RESULTS: Twenty-two (90)Y treatments were performed in 20 patients before transplantation. Median time from first treatment to transplantation was 3.5 months. HCC in 14 patients met the Milan criteria at the time of the first (90)Y treatment, and HCC in six did not. All cases that originally met the Milan criteria remained within the criteria before transplantation, and two of six patients whose disease did not meet the criteria (33%) had their disease successfully downstaged to meet the criteria. Overall, nine patients (45%) had complete or partial radiologic response to (90)Y radioembolization according to modified Response Evaluation Criteria In Solid Tumors. Complete necrosis of tumor with no evidence of viable tumor on pathologic examination was observed in five patients (36%) whose disease met the Milan criteria. CONCLUSIONS: Particularly in regions with long wait list times, (90)Y treatment is effective in maintaining tumor size in potential liver transplantation candidates with HCC. In addition, it can also be considered as a downstaging therapy in select patients before transplantation.

Successful transduction of liver in hemophilia by AAV-Factor IX and limitations imposed by the host immune response.

We have previously shown that a single portal vein infusion of a recombinant adeno-associated viral vector (rAAV) expressing canine Factor IX (F.IX) resulted in long-term expression of therapeutic levels of F.IX in dogs with severe hemophilia B. We carried out a phase 1/2 dose-escalation clinical study to extend this approach to humans with severe hemophilia B. rAAV-2 vector expressing human F.IX was infused through the hepatic artery into seven subjects. The data show that: (i) vector infusion at doses up to 2 x 10(12) vg/kg was not associated with acute or long-lasting toxicity; (ii) therapeutic levels of F.IX were achieved at the highest dose tested; (iii) duration of expression at therapeutic levels was limited to a period of approximately 8 weeks; (iv) a gradual decline in F.IX was accompanied by a transient asymptomatic elevation of liver transaminases that resolved without treatment. Further studies suggested that destruction of transduced hepatocytes by cell-mediated immunity targeting antigens of the AAV capsid caused both the decline in F.IX and the transient transaminitis. We conclude that rAAV-2 vectors can transduce human hepatocytes in vivo to result in therapeutically relevant levels of F.IX, but that future studies in humans may require immunomodulation to achieve long-term expression.

Management of unresectable symptomatic focal nodular hyperplasia with arterial embolization.

Symptomatic focal nodular hyperplasia (FNH) of the liver can usually be treated safely with liver resection. However, in those patients in whom resection is not possible because of the location or size of the tumor or other patient factors, selective arterial embolization should be considered. Herein, the authors describe the use of arterial embolization to treat three women with symptomatic FNH and provide a review of the literature.

Treatment of unresectable cholangiocarcinoma with gemcitabine-based transcatheter arterial chemoembolization (TACE): a single-institution experience.

BACKGROUND: Survival for patients with unresectable cholangiocarcinoma is reported to range from only 5-8 months without treatment. Systemic chemotherapy has not been shown to significantly improve survival, but newer regimens involving gemcitabine have shown increased response rates. Transcatheter arterial chemoembolization (TACE) has been shown to prolong survival in hepatocellular carcinoma patients, but experience using TACE in the treatment of cholangiocarcinoma is limited. We report our experience treating cholangiocarcinoma with TACE using chemotherapeutic regimens based on the well-tolerated drug gemcitabine. METHODS: Forty-two patients with unresectable cholangiocarcinoma were treated with one or more cycles of gemcitabine-based TACE at our institution. Chemotherapy regimens used for TACE included: gemcitabine only (n=18), gemcitabine followed by cisplatin (n=2), gemcitabine followed by oxaliplatin (n=4), gemcitabine and cisplatin in combination (n=14), and gemcitabine and cisplatin followed by oxaliplatin (n=4). RESULTS: Patients were 59 years of age (range 36-86) and received a median of 3.5 TACE treatments (range 1-16). Thirty-seven patients (88%) had central cholangiocarcinoma, and five (12%) had peripheral tumors. Nineteen patients (45%) had extrahepatic disease. Grade 3 adverse events (AEs) after TACE treatments were seen in five patients, whereas grade 4 AEs occurred in two patients. No patients died within 30 days of TACE. Median survival from time of first treatment was 9.1 months overall. Results did not vary by patient age, sex, size of largest initial tumor, or by the presence of extra-hepatic disease. Treatment with gemcitabine-cisplatin combination TACE resulted in significantly longer survival (13.8 months) compared to TACE with gemcitabine alone (6.3 months). CONCLUSIONS: Our report represents the largest series to date regarding hepatic-artery-directed therapy for unresectable cholangiocarcinoma and provides evidence in favor of TACE as a promising treatment modality in unresectable cholangiocarcinoma. Our results suggest that gemcitabine-based TACE is well tolerated and confers better survival when given in combination therapy (with cisplatin or oxaliplatin) for patients with unresectable cholangiocarcinoma.

Posttransplant lymphoproliferative disorders presenting at sites of previous surgical intervention.

Early diagnosis of posttransplant lymphoproliferative disorder (PTLD) requires a high level of clinical suspicion. PTLD occurs mainly in the lymphoid tissue, allograft organ, bowel, and central nervous system. The diagnosis may not be considered initially when disease is localized to other sites. Retrospective review of the PTLD series at the University of Pittsburgh Medical Center showed that 4 of 418 patients (1%) presented with signs and symptoms localized to sites of previous surgical intervention (choledochojejunostomy site, ileosigmoid anastomotic site, site of saphenous vein stripping, and intrabiliary site of percutaneous transhepatic catheter). All patients showed symptomatic, Epstein-Barr virus-positive B-cell PTLD of varying histology. Three of four patients ultimately died with tumor, and the fourth died of unrelated causes. PTLD should be included in the differential diagnosis when clinical signs and symptoms localize to anastomotic sites, surgical incision sites, or sites of longstanding catheter placement in immunosuppressed organ transplant recipients.

Combined surgical and interventional radiologic management strategies in patients with arterial pseudo-aneurysms after multivisceral transplantation.

BACKGROUND: Multivisceral transplantation has recently evolved to be a life-saving procedure for patients with intestinal failure and complex abdominal pathology. A composite aortic graft is always needed to restore the arterial flow to the transplanted organs. Accordingly, arterial complications can be life-threatening requiring prompt intervention. Herein, we describe innovative technical approaches in seven recipients who developed pseudo-aneurysm (PA) after transplantation. METHODS: With a total of 285 composite visceral transplants, 15 (5.2%) patients experienced vascular complications. Of these, 7 were life-threatening PAs that were diagnosed 61 to 2677 days after transplantation. Due to the anatomic and technical complexity of the allograft vasculature, endovascular techniques were introduced alone (n=2) or in conjunction with surgical intervention (n=5) in an attempt to rescue patients and salvage the transplanted organs. RESULTS: The endovascular and surgical technical approaches used for each of the 7 PA actively bleeding patients was successful in 5 (71%). Of these, 2 (40%) are alive 86 to 117 months after the intervention. The remaining 5 recipients died of recurrent hemorrhage (n=2), liver failure (n=1), and pneumonia (n=1). The cause of death was unknown in the remaining patient. Retransplantation and intra-abdominal infections were major risk factors. Candida was the most common isolated microorganism. CONCLUSIONS: Recipients of composite visceral allografts are at risk of developing life-threatening PAs, particularly in those with early posttransplantation abdominal infections. Prompt multidisciplinary diagnosis and therapeutic approaches are crucial management strategies.

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation.

PURPOSE: To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation. MATERIALS AND METHODS: Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures. RESULTS: By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p=0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p<0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p=0.01); however, using both techniques, sensitivity increased to 95%. CONCLUSIONS: MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.

Yttrium-90 radioembolization for colorectal cancer liver metastases: a single institution experience.

Purpose. We sought to evaluate our experience using yttrium-90 ((90)Y) resin microsphere hepatic radioembolization as salvage therapy for liver-dominant metastatic colorectal cancer (mCRC). Methods. A retrospective review of consecutive patients with unresectable mCRC who were treated with (90)Y after failing first and second line systemic chemotherapy. Demographics, treatment dose, biochemical and radiographic response, toxicities, and survival were examined. Results. Fifty-one patients underwent (90)Y treatments of which 69% were male. All patients had previously undergone extensive chemotherapy, 31% had undergone previous liver-directed therapy and 24% had a prior liver resection. Using RECIST criteria, either stable disease or a partial response was seen in 77% of patients. Overall median survival from the time of first (90)Y treatment was 10.2 months (95% CI = 7.5-13.0). The absence of extrahepatic disease at the time of treatment with (90)Y was associated with an improved survival, median survival of 17.0 months (95% CI = 6.4-27.6), compared to those with extrahepatic disease at the time of treatment with (90)Y, 6.7 months (95% CI = 2.7-10.6 CONCLUSION: (90)Y therapy is a safe locoregional therapy that provides an important therapeutic option to patients who have failed first and second line chemotherapy and have adequate liver function and performance status.

Biliary complications after orthotopic liver transplantation.

Liver transplantation has made many advances since its inception in the early 1970s. Despite volumes of basic science and clinical research related to liver transplantation, biliary complications continue to present the interventional radiologist with challenging cases in all transplant centers. Biliary complications can range from minor complications such as contained bile leaks to severe complications such as biliary necrosis resulting from hepatic artery thrombosis. Minor complications may require minimal or no intervention, whereas the more severe complications can require urgent surgery. To treat biliary complications such as anastomotic strictures, nonanastomotic strictures, biliary leaks, sludge or biliary necrosis, an accurate diagnosis must first be obtained. One must also be aware of how these complications can impair both allograft and transplant patient survival. With this information one can then plan a treatment knowing the potential success rates of specific treatments. Using proper technique with this information at hand can greatly increase the success rate in treating the spectrum of biliary complications. Interventional radiology serves a critical role in diagnosis and treatment of these liver transplant biliary complications and is important to the success of all transplant programs.

Chemo-embolization for unresectable hepatocellular carcinoma with different sizes of embolization particles.

The purpose of this study was to evaluate the size responses and vascular responses to three different sizes of Embosphere (EMBS) embolization particles used for chemo-embolization in patients with unresectable hepatocellular carcinoma (HCC). Forty-seven patients with biopsy proven HCC treated with TACE using EMBS (Biosphere Medical, Rockland, MA, USA) were included in this study. EMBS are non-resorbable tris-acryl gelatin defined-size microspheres. Sixteen patients were treated with 40-120 micron (40-microm), 13 patients with 100-300 (100-microm), and 18 patients with 300-500 (300-microm) EMBS particles. We measured the two-dimensional area and vascularity of the tumor index lesion on initial and subsequent CTs after treatment. Lesions were classified into four grades based on the degree of vascularity measured in 25% increments. Size of tumor after one treatment decreased by an average (avg) of 18% for 40-120-microm particles, 38% for 100-300-microm particles, and 17% for 300-500-microm particles. After three treatments, size decreased by an avg of 46% for 40-120-microm particles, 76% for 100-300-microm particles, and 46% for 300-500-microm particles. Vascularity decrease was also measured after the first and third treatments, and defined as a decrease of one or more grades in tumor vascularity. Results were as follows (% of patients with decrease). For 40-120-microm particles: 1 and 3 treatments, 53% and 88% of patients. For 100-300-microm particles: 1 and 3 treatments, 60% and 88% of patients. For 300-500-microm particles: 1 and 3 treatments, 50% and 57% of patients. It was concluded the 100-300-microm EMBS particles produce slightly higher responses.

Migration of the Günther Tulip inferior vena cava filter to the chest.

The authors describe two cases in which Günther Tulip inferior vena cava filters migrated to the chest, necessitating open-heart surgery for retrieval. In the first case, a 52-year-old man was transferred to their hospital from an outside facility after the filter migrated to the main pulmonary artery during attempted filter placement. In the second case, a 72-year-old man, a Günther Tulip filter was found to have migrated to the tricuspid valve after cardiopulmonary arrest and subsequent resuscitation, including emergent central venous line placement. The authors present the relevant details of both cases, discuss possible preventive strategies, and review the available literature about migration of the Günther Tulip filter.

Interventional radiology in liver transplantation.

Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation.

Vascular access: comparison of US guidance with the sonic flashlight and conventional US in phantoms.

PURPOSE: To prospectively evaluate whether ultrasonography (US)-guided vascular access can be learned and performed faster with the sonic flashlight than with conventional US and to demonstrate sonic flashlight-guided vascular access in a cadaver. MATERIALS AND METHODS: Institutional review board approval and oral and written informed consent were obtained. The sonic flashlight replaces the standard US monitor with a real-time US image that appears to float beneath the skin and is displayed where it is scanned. In studies 1 and 2, participants performed sonic flashlight-guided needle insertion tasks in vascular phantoms. In study 1, 16 participants (nine women, seven men) with no US experience performed 60 simulated vascular access trials with sonic flashlight or conventional US guidance. With analysis of variance (ANOVA) and power-curve fitting, improvement with practice rate and mean differences between techniques and tasks were examined. In study 2, 14 female nurses (mean age, 50.1 years) proficient with conventional US performed simulated vascular access trials on three tasks with the sonic flashlight and conventional US. With random assignment, half the participants used the sonic flashlight first and half used conventional US first. Mean performance with each technique and that with each task were compared by using ANOVA. In study 3, feasibility of sonic flashlight guidance for access to internal jugular and basilic veins was demonstrated in a cadaver. RESULTS: For study 1, learning rates (ie, decrease in access time over trials) did not differ for vascular access with sonic flashlight and conventional US. Overall, participants achieved faster vascular access times with sonic flashlight guidance (P < .007). In study 2, participants performed procedures faster overall with the sonic flashlight (P < .02) and found the sonic flashlight easier to use. In study 3, sonic flashlight-guided vascular access was gained in the cadaver. CONCLUSION: Learning and performance of vascular access were significantly faster with the sonic flashlight than with conventional US, and vascular access could be gained in a cadaver; the sonic flashlight is ready for clinical trials.

Evaluation of responses to chemoembolization in patients with unresectable hepatocellular carcinoma.

BACKGROUND: The authors used computed tomography (CT) scans to correlate the changes in tumor vascularity, necrosis, and size with response and survival after transcatheter arterial chemoembolization (TACE) in patients with advanced, unresectable, hepatocellular carcinoma (HCC). METHODS: The authors studied 72 patients with biopsy-proven, unresectable HCC and focused on 186 individual tumor masses. A baseline, multiphase, helical CT was performed and at least three follow-up CT scans were performed after treatment by TACE. Tumors were classified as hypervascular or hypovascular and patients were classified as responders or nonresponders based on CT evidence of altered tumor size, tumor necrosis, and the appearance of new tumors. A new scoring system was used to monitor patient response to TACE. RESULTS: Thirty-eight patients were responders and 34 were nonresponders. Patient survival was significantly increased (P = 0.009) in patients who were hypervascular responders. Survival also was increased in hypervascular nonresponders compared with hypovascular nonresponders (P = 0.008) and in hypovascular responders compared with hypovascular nonresponders (P = 0.002). Response to chemoembolization was found to be significantly (P = 0.02) and inversely proportional to tumor size, but the number of tumor foci in an individual patient was not predictive. CONCLUSIONS: TACE appears to result in improved survival among HCC patients with hypervascular tumors who responded to therapy. However, even patients classified by CT as hypervascular nonresponders and hypovascular responders have improved survival.

Effectiveness of coiling in the treatment of endoleaks after endovascular repair.

BACKGROUND: Persistent endoleaks are a common problem following endovascular repair of abdominal aortic aneurysms, and the best method of treatment has been an issue of debate. Some experimental evidence has suggested that coiling may not be an effective method because it allows transmission of pressure across the coils with continued expansion of the sac. We reviewed our experience with endoleak coiling to assess the degree of clinical success of this treatment. METHODS: A retrospective review of patients with type I or type II endoleaks treated solely by coiling over a 7-year period (1997-2003) was performed. All endoleaks had been observed for at least 6 months prior to intervention to detect spontaneous resolution. All coils were delivered by selective catheterization of the endoleaks. For Type II endoleaks, the branches were all coiled at their junction with the sac when feasible and the endoleak cavity was packed. Clinical success was defined as cessation of endoleak on follow-up computed tomography as well as no further aneurysmal growth (> or =5mm minor axis). RESULTS: Twenty-eight patients had their endoleaks treated only with coils. There were 22 Ancure, 2 Excluder, 2 AneuRx, and 2 Lifepath endografts in this patient cohort. Procedural morbidity was 0%. Mean follow-up after coiling for all patients was 18 months (range, 1-60 months) while mean follow-up for patients with a type I endoleak was 24 months. Clinical success was achieved in 15 of 19 (79%) patients with type II endoleaks and 8 of 9 (89%) patients with type I. Three patients, all with type I endoleak, required more than 1 episode of coiling, while 2 others, both with type II lumbar endoleaks, required repeat angiography due to inability to access the leak during the first attempt. There were 2 proximal and 6 distal type I endoleaks (2 aortic, 6 iliac) successfully treated while the type II successes included 8 inferior mesenteric artery and 7 sole lumbar endoleaks. Five patients continued to show evidence of endoleak over time: 2 endoleaks were associated with aneurysm growth leading to conversion in 1 patient, 2 patients with type II endoleaks are stable, and the sole type I endoleak with continued perigraft flow has shown significant shrinkage of the sac and continues to be observed 18 months later. No ruptures were noted during follow-up. CONCLUSION: Coiling as the sole method of endoleak management may be a suitable treatment option in selected patients. Clinical success can be expected in over 80% of patients with type II and select type I endoleaks, with minimal morbidity.