Surgical treatment patterns and clinical outcomes of patients treated for expanding aneurysm sacs with type II endoleaks following EVAR

Abstract Objective Persistent type II endoleaks (T2ELs) following endovascular aneurysm repair (EVAR) with sac growth have been associated with adverse events, including rupture. While intervention in the presence of aneurysm growth has become an accepted treatment paradigm for T2ELs, the efficacy and clinical success of such interventions remain unclear. Therefore, we examined the treatment patterns and clinical outcomes of patients undergoing T2EL interventions after EVAR. Methods We performed a retrospective review of all patients treated for expanding aneurysm sacs with T2ELs following EVAR at an academic medical center between 2006–2017. The primary outcomes assessed were need for repeat intervention, intervention types, and achievement of clinical success – defined as stable aneurysm sac size on computed tomography angiogram (CTA) following treatment. Results Fifty-six patients underwent 119 interventions, of which 107 (90%) were technically successful. The median time from EVAR to index T2EL procedure was 37 months [IQR: 17-56], and the median follow-up time from first T2EL procedure was 27 months [IQR: 10-51]. The most common index procedure was transarterial lumbar embolization (64%), followed by transarterial IMA (20%), transcaval (14%), and translumbar embolization (1.8%). Thirty-three (59%) patients required further procedures for persistent aneurysm sac expansion. For subsequent T2EL interventions, the most common endovascular procedure was transarterial lumbar embolization (21%), followed by transcaval (21%), translumbar (11%), and transarterial IMA embolization (8.6%). Twelve patients (21%) were found to have loss of proximal and/or distal seal on subsequent imaging and required graft extensions to stabilize aneurysm sac size. Ten patients (18%) ultimately underwent graft explant or sacotomy with oversewing of the endoleak source. Freedom-from any endoleak-related reintervention was 57% at 1-year and 36% at 3-years. Freedom-from open treatment was 93% at 1-year and 82% at 3-years. Of the 44 patients with ≥6 months follow-up, 39 (89%) achieved clinical success. However, only 11 patients (25%) achieved clinical success without any further reintervention, and 29 patients (66%) achieved clinical success without open treatment. Conclusions Despite high technical success, endoleak recurrence after T2EL treatment is common and multiple interventions are often needed to stabilize aneurysm sac size in patients diagnosed with T2EL-associated sac growth. Notably, one in five patients treated for T2ELs were discovered, upon further evaluation, to have proximal/distal seal zone losses that necessitated repair to achieve sac stability. Thus, thorough assessment of all endoleak types should be performed in patients with T2ELs associated with sac growth prior to T2EL treatment to ensure appropriate care and minimize ineffective interventions.