Incidence and Long-Term Implications of Type 2 Endoleak after Endovascular Repair of Abdominal Aortic and Aortoiliac Aneurysms

Abstract

Type 2 endoleak has been proved not to significantly increase the risk of aneurysm rupture. However, it is associated with aneurysm enlargement and may require secondary interventions. Its role has been widely investigated, but a definitive consensus about its management has still not been obtained. We performed a retrospective, single-center observational study that investigates the incidence of type 2 endoleak and its implications in the long-term follow-up in all the patients who underwent endovascular aortic repair (EVAR) for abdominal aortic aneurysm from 2011 to 2016 at our institution. A total of 216 patients who underwent EVAR during the specified time period were enrolled, and 85 of them (39%) developed type 2 endoleak in their follow-up. Thirty-one of the patients who developed type 2 endoleak faced an aneurysm sac growth > 10 mm and required secondary intervention. Only nine of them showed resolution of the leak. In the long-term follow-up, patients who developed type 2 endoleak after EVAR did not show a significantly increased mortality compared with those who did not, but some of them required late open conversion due to aneurysm sac enlargement and some other developed a secondary type 1 endoleak which required correction. The management of type 2 endoleak remains debated, despite consensus exist regarding the need for intervention when a > 10-mm aneurysm sac growth is observed. Further studies are necessary to better define which are the “high-risk” type 2 endoleaks and identify the patients who would benefit more from correction.

Keywords

abdominal aortic aneurysm - endovascular repair - aneurysm - coil embolization - endograft placement - endovascular procedure - iliac artery disease

Publication History

Article published online:
25 July 2023

• References

• 1 Boyle JR, Mao J, Beck AW. et al. Editor's Choice - variation in intact abdominal aortic aneurysm repair outcomes by country: analysis of International Consortium of Vascular Registries 2010 - 2016. Eur J Vasc Endovasc Surg 2021; 62 (01) 16-24
• 2 Prinssen M, Verhoeven EL, Buth J. et al; Dutch Randomized Endovascular Aneurysm Management (DREAM)Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351 (16) 1607-1618
• 3 Lederle FA, Kyriakides TC, Stroupe KT. et al; OVER Veterans Affairs Cooperative Study Group. Open versus endovascular repair of abdominal aortic aneurysm. N Engl J Med 2019; 380 (22) 2126-2135
• 4 Dijkstra ML, Zeebregts CJ, Verhagen HJM. et al; ENGAGE investigators. Incidence, natural course, and outcome of type II endoleaks in infrarenal endovascular aneurysm repair based on the ENGAGE registry data. J Vasc Surg 2020; 71 (03) 780-789
• 5 Wanhainen A, Verzini F, Van Herzeele I. et al; Esvs Guidelines Committee. Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg 2019; 57 (01) 8-93
• 6 Hajibandeh S, Ahmad N, Antoniou GA, Torella F. Is intervention better than surveillance in patients with type 2 endoleak post-endovascular abdominal aortic aneurysm repair?. Interact Cardiovasc Thorac Surg 2015; 20 (01) 128-134
• 7 van Marrewijk C, Buth J, Harris PL, Norgren L, Nevelsteen A, Wyatt MG. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience. J Vasc Surg 2002; 35 (03) 461-473
• 8 van Marrewijk CJ, Fransen G, Laheij RJ, Harris PL, Buth J. EUROSTAR Collaborators. Is a type II endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up. Eur J Vasc Endovasc Surg 2004; 27 (02) 128-137
• 9 Mascoli C, Freyrie A, Gargiulo M. et al. Selective intra-procedural AAA sac embolization during EVAR reduces the rate of type II endoleak. Eur J Vasc Endovasc Surg 2016; 51 (05) 632-639
• 10 Fabre D, Fadel E, Brenot P. et al. Type II endoleak prevention with coil embolization during endovascular aneurysm repair in high-risk patients. J Vasc Surg 2015; 62 (01) 1-7
• 11 Manunga JM, Cragg A, Garberich R. et al. Preoperative inferior mesenteric artery embolization: a valid method to reduce the rate of type II endoleak after EVAR?. Ann Vasc Surg 2017; 39: 40-47
• 12 Biancari F, Mäkelä J, Juvonen T, Venermo M. Is inferior mesenteric artery embolization indicated prior to endovascular repair of abdominal aortic aneurysm?. Eur J Vasc Endovasc Surg 2015; 50 (05) 671-674
• 13 Carpenter JP, Cuff R, Buckley C. et al; Nellix Investigators. One-year pivotal trial outcomes of the Nellix system for endovascular aneurysm sealing. J Vasc Surg 2017; 65 (02) 330-336.e4
• 14 Singh AA, Benaragama KS, Pope T. et al. Progressive device failure at long term follow up of the Nellix EndoVascular Aneurysm Sealing (EVAS) system. Eur J Vasc Endovasc Surg 2021; 61 (02) 211-218
• 15 Lo RC, Buck DB, Herrmann J. et al; Vascular Study Group of New England. Risk factors and consequences of persistent type II endoleaks. J Vasc Surg 2016; 63 (04) 895-901
• 16 Dias NV, Ivancev K, Malina M, Resch T, Lindblad B, Sonesson B. Intra-aneurysm sac pressure measurements after endovascular aneurysm repair: differences between shrinking, unchanged, and expanding aneurysms with and without endoleaks. J Vasc Surg 2004; 39 (06) 1229-1235
• 17 Ultee KHJ, Büttner S, Huurman R. et al. Editor's Choice - systematic review and meta-analysis of the outcome of treatment for type II endoleak following endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2018; 56 (06) 794-807