Management of Endoleaks After Elective Infrarenal Aortic Endovascular Aneurysm Repair

Abstract

ImportanceEndovascular aneurysm repair (EVAR) is the dominant treatment strategy for abdominal aortic aneurysms, encompassing 80% of all repairs in the United States. Endoleaks are ubiquitous and affect 30% of patients treated by EVAR, potentially leading to sac enlargement and increased risk of rupture. The care of EVAR patients requires long-term surveillance by a multidisciplinary team. Accordingly, physicians should be familiar with the fundamentals of endoleak management to achieve optimal outcomes, including timely referral for remediation or providing counseling and reassurance when needed.ObservationsPubMed and the Cochrane database were searched for articles published between January 2002 and December 2022 in English, addressing epidemiology, diagnosis, and management of endoleaks after EVAR. Endoleaks can be detected intraoperatively or years later, making lifelong surveillance mandatory. Type I and III have the highest risk of rupture (7.5% at 2 years and 8.9% at 1 year, respectively) and should be treated when identified. Intervention should be considered for other types of endoleak when associated with aneurysm sac growth larger than 5 mm based on current guidelines. Type II endoleaks are the most common, accounting for 50% of all endoleaks. Up to 90% of type II endoleaks resolve spontaneously or are not associated with sac enlargement, requiring only observation. Although the risk of rupture is less than 1%, cases that require reintervention are challenging. Recurrence is common despite endovascular treatment, and rupture can occur without evidence of sac growth. Type IV endoleaks and endotension are uncommon, are typically benign, and primarily should be observed.Conclusions and RelevanceEndoleak management depends on the type and presence of sac expansion. Type I and III endoleaks require intervention. Type II endoleaks should be observed and treated selectively in patients with significant sac expansion. Since endoleaks can appear any time after EVAR, at least 1 contrast-enhanced computed tomographic angiogram or duplex ultrasound by an experienced laboratory is recommended every 5 years.

Diagnosis of Type IV Endoleak After Endovascular Aneurysm Repair Using Visualization With Novel Software

“…A Type IV endoleak is defined as early leakage through the pores of an otherwise intact endovascular graft [ 5 ], though it is very rare, with a reported frequency of approximately 0.3%. In general, a reoperation is not generally required even long after the performance of an EVAR, thus follow-up examinations alone are often chosen [ 6 ]. On the other hand, when an endoleak is observed following that repair procedure for a large aneurysm, differential diagnosis is very important and additional treatment may be required in some cases.…”

Dynamic Radial MR Imaging for Endoleak Surveillance after Endovascular Repair of Abdominal Aortic Aneurysms with Inconclusive CT Angiography: A Prospective Study

“…Endoleaks, characterized by persistent blood flow within the aneurysm sac yet external to the stent-graft lumen, represent the predominant complication following EVAR, occurring in 20-50% of cases [2,[8][9][10]. Persistent blood flow to the aneurysm sac due to undetected endoleaks can precipitate the continued expansion of the aneurysm, elevating the risk of eventual rupture [1, 7,8,10,11].…”

“…Endoleaks, characterized by persistent blood flow within the aneurysm sac yet external to the stent-graft lumen, represent the predominant complication following EVAR, occurring in 20-50% of cases [2,[8][9][10]. Persistent blood flow to the aneurysm sac due to undetected endoleaks can precipitate the continued expansion of the aneurysm, elevating the risk of eventual rupture [1, 7,8,10,11]. This scenario underscores the indispensable role of surveillance for the early detection and timely management of endoleaks, thereby mitigating the risk of aneurysm growth and rupture [1, [6][7][8].…”