Endotension: twenty years of a controversial term

Abstract

Use of the term endotension in the treatment of aortic aneurysm is currently controversial. Initially it was proposed to define the circumstance in which there is an enlargement of the aneurysm sac after endovascular repair without a demonstrable endoleak. The term was established with the aim of transmitting the possibility of causes other than pressure applying stress to the aneurysm wall. Twenty years have passed since the proposal of this terminology was published. The literature is reviewed with the purpose of providing an update on advances in the knowledge of the possible etiological mechanisms. The experimental studies call into question that causes other than pressure determine the increase of the aneurysm. On the basis of this review, the term `Sac Expansion Without Evident Leak´ (SEWEL) is proposed as a more accurate and precise denomination for what is aimed to be defined. Evidence suggests that the more likely mechanisms of persistent pressurization of the aneurysm sac are an unidentified endoleak (likely type I or low-flow Type II) or thrombus occluding wide and short channels that connects with the excluded aneurysm sac (at the attachment sites of the stent-graft or at the branch vessels orifices).

Late Type III Endoleak after Loss of Component Overlap after EVAR with AFX2 Device: A Case Report

“…In our case, the sac initially showed an increased size without a clear endoleak and was thus diagnosed as endotension [14]. Endotension is generally attributed to unrecognized endoleaks, pressure transmission through the endograft wall, or transudate migration through the endograft owing to porosity [15]. In the case of true endotension without an undetected endoleak, blood is absent in the aneurysmal sac and rupture is unlikely to cause massive hemorrhage [16].…”

Pseudoendoleak: A post‐endovascular aortic repair ultrasound surveillance pitfall – Single institution case series

“…Each case was preceded by aneurysm sac expansion on serial imaging, prompting the index ultrasound allowing for a diagnosis of SEWEL to be made. 12 As an ultrasound-based technique, flow on CDUS and MFI is sensitive in demonstrating fluid movement (i.e. blood flow) but is limited in its specificity.…”

“…Each case in our series demonstrates a positive CDUS in the context of post‐EVAR surveillance, with extravascular doppler or MFI signal within the aneurysm sac, if followed by CEUS without demonstrable (Type I–IV) endoleak. Each case was preceded by aneurysm sac expansion on serial imaging, prompting the index ultrasound allowing for a diagnosis of SEWEL to be made 12 …”

“…Each case was preceded by aneurysm sac expansion on serial imaging, prompting the index ultrasound allowing for a diagnosis of SEWEL to be made. 12 …”

Enlarging aneurysm sac post EVAR – type V or occult type II Endoleak?

“…However, persistence of T5ELs with newer generation endografts has led to several hypotheses including intermittent or low-flow endoleaks not visualised on imaging (Sambeek et al 2004;Torres-Blanco and Miralles-Hernández 2021;Parsa et al 2021). Other authors postulate hyperfibrinolysis and local coagulation activation as the mechanism of a clear gelatinous material accumulating within the aneurysm sac, known as sac hygroma (Risberg et al 2001(Risberg et al , 2004.…”