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Patients who have a Type 2 endoleak (continued blood flow into the repaired aneurysm sac through small arterial branches of the aorta that are excluded by stent grafts) for more than six months after endovascular abdominal repair (EVAR), should be considered for early reintervention irrespective of a change of a aneurysm sac size.  This information was presented at the 60th Annual Meeting of the Society of Vascular Surgery.

John Jones, MD, clinical and research fellow in the vascular and endovascular surgery department, Massachusetts General Hospital in Boston, and lead author of the study said that although EVAR is an effective and increasingly used method of repairing abdominal aortic aneurysms, its long-term durability continues to be investigated. "Many EVAR patients have common Type 2 endoleaks which contribute significantly to adverse late outcomes, including increased risk for aneurysm rupture, aneurysm sac growth and conversion to open repair.  These risks do not diminish four to five years after EVAR.”  

One hundred and sixty-four patients with Type 2 endoleaks were studied.  Only those with a sac enlargement of more than 5 mm were selected for reintervention. At mean follow up (38.2 months) 131 patients had complete and permanent leak resolution within six months and there were 33 persistent endoleaks. Of the 33, only two of those endoleaks resolved spontaneously. Patients with Type 2 endoleaks had a significantly increased rate of conversion to open surgery compared to all other patients (9.1 vs. 2.3 percent). Six patients underwent conversion to open repair (2 ruptures, 3 persistent leak with gradual sac enlargement, 1 rapid sack enlargement.
 
Patients with persistent leaks had a significantly increased rate of reintervention (48.8 vs. 10.3 percent). The reasons for re-intervention were persistent endoleaks associated with sac expansion, the procedure being warranted by the surgeon or a rupture did no require open repair. Twenty-one catheter-based reinterventions were performed on 16 patients; there were 13 trans-arterial embolizations, five trans-lumbar embolizations, two graft revisions/stents and one lumbar artery ligiation. Only nine of the interventions were successful. Success was defined as leak resolution with a sac size that either decreased or remained stable.

At 1, 3 and 5 years respectively the freedom from rupture for all patients with persistent endoleaks was 96.7 percent, 96.7 percent and 91.4 percent; freedom from rupture for those who had leak resolution at six months was 98.8 percent, 96.3 percent and 96.3 percent. Twenty-seven of the endoleaks were treated with coil embolization, oversized stent, repeat endograft, but complete resolution as achieved in only 15 of the persistent endoleak patients. Additionally, freedom from sac expansion at 1,3 and 5 years was 97.5 percent, 94.5 percent and 88.1 percent for no leaks and 88.1 percent, 51.5 percent and 32.8 percent for persistent leaks.

Overall survival was not significantly different between patient with or without a Type 2 endoleak, however smoking history was a significant predictor of developing one (56 percent), however other risk factors, such as coumadin use, congestive heart failure and renal failure were not.

Co-authors of the study, also from Massachusetts General Hospital, said they were successful in treating about 60 percent of the patients with persistent endoleaks. They said that evidence with the approximately 45 percent who had a benign course still favors early intervention, because even patients without sac enlargement can have adverse events, including rupture. Furthermore, the risk of aneurysm sac growth in patients with persistent endoleak does not appear to decrease in time. Spontaneous resolution of such endoleaks is rare, so conservative management of these patients equals a long period of frequent surveillance, they added.

Researchers added that with the negative impact of Type 2 endoleaks on patients undergoing EVAR the study showed that to prevent adverse outcomes a more aggressive approach to management of these endoleaks should be strongly considered.