The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management

Abstract

An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta above 3 cm or 50% greater than the segment above. It is a dangerous condition accounting for a substantial number of deaths per year and increasing at an alarming rate. Various factors come into play in the development of AAAs, which this study has elaborated on, including smoking and old age, demographics, and comorbid conditions. Endovascular aneurysm repair (EVAR) is a newer treatment modality used for AAAs in which an endograft device is placed into the aorta, thereby creating a bypass tract from the aneurysm and generating flow mimicking that of the natural aorta. It is minimally invasive and associated with less postoperative mortality and reduced hospital stay. However, EVAR is also associated with significant postoperative complications, including endoleaks, which were reviewed in depth. Endoleaks are postprocedural leaks into the aneurysm sac that are usually identified immediately after graft placement and indicate treatment failure. They are of five subtypes, categorized according to their mechanism of development. The most common type is type II endoleaks, and the most dangerous is type I endoleaks. Each subtype has multiple management options with varying rates of success. Prompt identification along with appropriate treatment of endoleaks can lead to better postoperative outcomes and improved quality of life for patients.

Micro-robotic percutaneous targeting of type II endoleaks in the angio-suite

“…Percutaneous type II endoleak targeting can be extremely challenging due to the small target size, long path, and narrow corridor for safe access [6]. Selective planning of arbitrary angulated trajectories via target point and entry point definition using different views allowed for selection of the most appropriate path.…”

“…Access to the aneurysm sac is typically achieved using an endovascular transarterial approach selectively targeting the feeding vessels via inferior mesenteric artery, accessory renal, median sacral, or internal iliac arteries. In cases where a transarterial approach is not possible, the only alternative access is the direct percutaneous puncture of the perfused endoleak nidus under imaging guidance [6]. This procedure can be very demanding due to difficult access and deep puncture with risk of organ perforation and bleeding.…”