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Esposito A, Pasqua R, Menna D, Giordano AN, Illuminati G, D’Andrea V. Percutaneous Retrograde Trans-Gluteal Embolization of Type 2 Endoleak Causing Iliac Aneurysm Enlargement after Endovascular Repair: Case Report and Literature Review. J Clin Med 2024; 13:2909. [PMID: 38792450 PMCID: PMC11122112 DOI: 10.3390/jcm13102909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/22/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Late type II endoleaks (T2ELs) arising from the internal iliac artery (IIA) may present during follow-up after endovascular aortic repair (EVAR) of aortoiliac aneurysm and may warrant embolization if enlargement of the aneurysmal sac is demonstrated. When coverage of the IIA ostium has been made due to extensive iliac disease, access options can be challenging. Different treatment options have been reported over recent years, and a careful selection of the best one must be made based on the characteristics of each case. The present study reports a simple and reproducible sheathless percutaneous superior gluteal artery (SGA) access and provides a discussion based on a review of the existing literature on this topic.
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Affiliation(s)
- Andrea Esposito
- Vascular and Endovascular Surgery Division, Cardiovascular Department, San Carlo Hospital, 85100 Potenza, Italy; (A.E.); (D.M.)
| | - Rocco Pasqua
- Vascular and Endovascular Surgery Division, Cardiovascular Department, San Carlo Hospital, 85100 Potenza, Italy; (A.E.); (D.M.)
- Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy; (G.I.); (V.D.)
| | - Danilo Menna
- Vascular and Endovascular Surgery Division, Cardiovascular Department, San Carlo Hospital, 85100 Potenza, Italy; (A.E.); (D.M.)
| | - Antonio Nicola Giordano
- Vascular and Endovascular Surgery Division, Cardiovascular Department, San Carlo Hospital, 85100 Potenza, Italy; (A.E.); (D.M.)
| | - Giulio Illuminati
- Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy; (G.I.); (V.D.)
| | - Vito D’Andrea
- Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy; (G.I.); (V.D.)
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Chun JY, de Haan M, Maleux G, Osman A, Cannavale A, Morgan R. CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair. Cardiovasc Intervent Radiol 2024; 47:161-176. [PMID: 38216742 PMCID: PMC10844414 DOI: 10.1007/s00270-023-03629-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/19/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Endoleaks represent the most common complication after EVAR. Some types are associated with ongoing risk of aneurysm rupture and necessitate long-term surveillance and secondary interventions. PURPOSE This document, as with all CIRSE Standards of Practice documents, will recommend a reasonable approach to best practices of managing endoleaks. This will include imaging diagnosis, surveillance, indications for intervention, endovascular treatments and their outcomes. Our purpose is to provide recommendations based on up-to-date evidence, updating the guidelines previously published on this topic in 2013. METHODS The writing group was established by the CIRSE Standards of Practice Committee and consisted of clinicians with internationally recognised expertise in endoleak management. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select publications in English and relating to human subjects up to 2023. The final recommendations were formulated through consensus. RESULTS Endoleaks may compromise durability of the aortic repair, and long-term imaging surveillance is necessary for early detection and correct classification to guide potential re-intervention. The majority of endoleaks that require treatment can be managed using endovascular techniques. This Standards of Practice document provides up-to-date recommendations for the safe management of endoleaks.
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Affiliation(s)
- Joo-Young Chun
- St George's University Hospitals NHS Foundation Trust, London, UK.
- St George's University of London, London, UK.
| | - Michiel de Haan
- Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Asaad Osman
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Robert Morgan
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
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Cifuentes S, Mendes BC, Tabiei A, Scali ST, Oderich GS, DeMartino RR. Management of Endoleaks After Elective Infrarenal Aortic Endovascular Aneurysm Repair: A Review. JAMA Surg 2023; 158:965-973. [PMID: 37494030 DOI: 10.1001/jamasurg.2023.2934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Importance Endovascular 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. Observations PubMed 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 Relevance Endoleak 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.
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Affiliation(s)
- Sebastian Cifuentes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Armin Tabiei
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Yamanaka K, Kawabata R, Hamaguchi M, Chomei S, Inoue T, Hasegawa S, Tsujimoto T, Koda Y, Miyahara S, Takahashi H, Okada T, Yamaguchi M, Okada K. Open Conversion with Explantation of Stent Grafts After Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm. Ann Vasc Surg 2023:S0890-5096(23)00523-X. [PMID: 37536432 DOI: 10.1016/j.avsg.2023.07.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Although endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is widely used worldwide, the fact that it is associated with increased rates of reintervention has been considered a problem. This study aimed to analyze the outcomes of primary open AAA repair and open conversion with explantation of stent grafts after EVAR. METHODS In this retrospective study, we enrolled 1,120 patients (open repair, n = 664; EVAR, n = 456) who underwent AAA repair at Kobe University from 1999 to 2019. Of the 664 patients who underwent open repair, 121 (patients who underwent primary open repair (POR) as a concomitant procedure and patients with ruptured AAA) were excluded from the study. The outcomes of POR were compared with those of open conversion with explantation of stent grafts. RESULTS Of the 543 patients who underwent open repair, 513 underwent POR and 30 underwent open conversion with explantation of stent grafts. The operation time for POR was significantly less than that for open conversion with explantation. During surgery, patients who underwent open conversion with explantation required significantly more transfusions of red cell concentrate, fresh frozen plasma, and platelet concentrate than those who underwent POR. Overall, 30 patients who underwent open conversion with explantation required a total of 48 reinterventions before surgery. Hospital mortality rates were 0.7% and 0% in the POR and open conversion with explantation groups, respectively (P = 0.62). Although overall survival at 5 years in the POR group was significantly better than that in the open conversion with explantation group (89.3 ± 1.7% vs. 79.5 ± 9.6%; P = 0.01), there were no significant differences between the 2 groups regarding the freedom from aortic event (hospital death, reintervention, and aortic death). According to the multivariate analysis, open conversion with explantation was not an independent risk factor for late death. There were 20 patients who were hesitant to undergo OCE, although we recommended OCE. In a subgroup analysis, the overall mean cost borne by patients who underwent EVAR was approximately 2.3 times higher compared with that borne by patients who underwent POR. CONCLUSIONS Although demanding, both early and long-term outcomes of OCE have been favorable in our present study. OCE is highly recommended in patients with persistent sac enlargement after EVAR.
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Affiliation(s)
- Katsuhiro Yamanaka
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Ryo Kawabata
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Mari Hamaguchi
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Shunya Chomei
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Taishi Inoue
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Shota Hasegawa
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Takanori Tsujimoto
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Yojiro Koda
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Shunsuke Miyahara
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Hiroaki Takahashi
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan
| | - Takuya Okada
- The Department of Radiology, University of Kobe, Kobe, Japan
| | | | - Kenji Okada
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Kobe, Japan.
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Bramucci A, Miceli F, Fontana A, Tusini N, Sereni G, Sassatelli R. Successful Endovascular and Endoscopic Treatment of a Symptomatic Celiac Artery Aneurysm for Obstructive Jaundice: A Clinical Case Report. Ann Vasc Surg 2021; 80:395.e1-395.e7. [PMID: 34808263 DOI: 10.1016/j.avsg.2021.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 10/04/2021] [Accepted: 10/27/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Celiac artery aneurysm (CAA) is an infrequent aneurysm of the celiac visceral branch and is potentially life-threatening, mainly due to the risk of rupture. CAA is often diagnosed following rupture and rarely diagnosed secondary to a primary manifestation; obstructive jaundice is extremely rare and poorly described. This clinical case report reports a combined endovascular and endoscopic noninvasive treatment. METHODS A 51-year old male was admitted to the emergency department at the Arcispedale Santa Maria Nuova in Reggio Emilia following several days of jaundice. The patient did not have any history of abdominal trauma, chronic pancreatitis, bile duct calculus or alcohol abuse. Cholestatic impairment was demonstrated by blood analyses and abdominal ultrasound revealed a large cephalo-pancreatic mass. Contrast-enhanced computed tomography (CT) showed a 40 mm CAA, causing a common bile duct (CBD) compression and dilatation of the hepatic bile ducts. After a multidisciplinary team consultation, a noninvasive, combined endovascular and endoscopic approach was programmed in a hybrid room. RESULTS Immediate results confirmed successful exclusion of the CAA, stent graft patency and the absence of endoleak with correct positioning of a plastic stent in the CBD. At 1 month, an abdominal CT-angiography (CTA) evidenced a type II endoleak, successfully treated with an endovascular secondary procedure and an asymptomatic, partial downward dislodgement of the plastic stent in the CBD was correct with the positioning of 2 plastic stents. At 3-months cholangiography showed no dilation of intraepatic biliary ducts. CONCLUSIONS Symptomatic CAA with common bile duct compression could be amenable to a combined endovascular and endoscopic noninvasive treatment.
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Affiliation(s)
- Alberto Bramucci
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Francesca Miceli
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL-IRCCS Reggio nell' Emilia, Reggio Emilia, Italy
| | - Antonio Fontana
- Vascular Surgery, AO Reggio Emilia, Arcispedale S.Maria Nuova, Reggio Emilia, Italy
| | - Nicola Tusini
- Vascular Surgery, AO Reggio Emilia, Arcispedale S.Maria Nuova, Reggio Emilia, Italy
| | - Giuliana Sereni
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL-IRCCS Reggio nell' Emilia, Reggio Emilia, Italy
| | - Romano Sassatelli
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL-IRCCS Reggio nell' Emilia, Reggio Emilia, Italy
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Dinoto E, Ferlito F, Urso F, Evola S, Bajardi G, Pecoraro F. Trans-limb embolization for treatment of Type 2 endoleak post EVAR: Case report. Int J Surg Case Rep 2021; 85:106238. [PMID: 34343793 PMCID: PMC8349994 DOI: 10.1016/j.ijscr.2021.106238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction Type 2 endoleaks (T2EL) occur after 10%–25% of endovascular abdominal aortic aneurysm repairs and increase the risk factor of endograft repair failure and rupture. Herein we report a case of endovascular treatment of T2EL where we performed a trans-limb embolization. Presentation of case A 63-years-old male previously treated for AAA with endovascular aortic aneurysms repair (EVAR), showed an angio-CT scan followup with a type 2 endoleak fed from inferior mesenteric artery (AMI) with growth of AAA greater of 1 cm than preoperative CT-scan and increase of chronic lumbar pain. Due to high risk of rupture was performed a trans-limb embolization with complete sealing. The 6 months CT-angiography showed complete type 2 endoleak exclusion without changes of AAA. Discussion The risk of aneurysm rupture in the presence of an isolated T2EL is exceptionally low. However, when a persistent T2EL is associated with a significant sac size increase, commonly considered as at least 5 mm over 6 months, should be treated. Detachable coils are repositionable, allowing an extremely precise deployment and subsequent embolization of different targets. Conclusion In this experience trans-limb embolization was feasible and this tool should be taken in account especially when no other surgical options exists. Type 2 endoleaks (T2EL) are a risk factor for endograft repair failure and rupture. T2EL are the most common endoleaks and remain the main cause of repeat intervention. Trans-limb embolization is an innovative technique for T2EL without standard access. Concerto are detachable coils repositionable allowing an extreme precise deployment.
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Affiliation(s)
- E Dinoto
- Vascular Surgery Unit - AOUP Policlinico 'P. Giaccone', Palermo, Italy.
| | - F Ferlito
- Vascular Surgery Unit - AOUP Policlinico 'P. Giaccone', Palermo, Italy
| | - F Urso
- Vascular Surgery Unit - AOUP Policlinico 'P. Giaccone', Palermo, Italy
| | - S Evola
- Unit of Cardiology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) 'G. D'Alessandro', University Hospital Paolo Giaccone, University of Palermo, Palermo, Italy
| | - G Bajardi
- Vascular Surgery Unit - AOUP Policlinico 'P. Giaccone', Palermo, Italy; Department of Surgical, Oncological and Oral Sciences, University of Palermo, Italy
| | - F Pecoraro
- Vascular Surgery Unit - AOUP Policlinico 'P. Giaccone', Palermo, Italy; Department of Surgical, Oncological and Oral Sciences, University of Palermo, Italy
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Charitable JF, Patalano PI, Garg K, Maldonado TS, Jacobowitz GR, Rockman CB, Veith FJ, Cayne NS. Outcomes of translumbar embolization of type II endoleaks following endovascular abdominal aortic aneurysm repair. J Vasc Surg 2021; 74:1867-1873. [PMID: 34197948 DOI: 10.1016/j.jvs.2021.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 06/11/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Presence of an endoleak can compromise aneurysm exclusion after endovascular abdominal aortic aneurysm repair (EVAR). Type II endoleaks (T2Es) are most common and may cause sac expansion. We report outcomes of translumbar embolization (TLE) of T2Es following EVAR. METHODS We conducted a retrospective chart review of patients with T2E after EVAR treated with TLE from 2011 to 2018 at a single academic institution. Treatment indications were the presence of persistent T2E and aneurysm growth ≥5 mm. Sac stabilization was defined as growth ≤5 mm throughout the follow-up period. RESULTS Thirty consecutive patients were identified. The majority were men (n = 24), with a mean age of 74.3 years (95% confidence interval [CI], 70.9-77.6 years). The most common comorbidities were hypertension (83.3%) and coronary artery disease (54.0%). The mean maximal sac diameter at T2E discovery was 5.8 cm (95% CI, 5.4-6.2 cm). The mean time to intervention from endoleak discovery was 33.7 ± 28 months with a mean growth of 0.84 cm (95% CI, 0.48-1.2 cm) during that time period. The mean follow-up time after TLE was 19.1 months (95% CI, 11.1-27.2 months). Twenty-eight patients were treated with cyanoacrylate glue (CyG) alone, and two were treated with CyG plus coil embolization (CE). There was immediate complete endoleak resolution as assessed intraoperatively, and sac stabilization in 15 cases (50.0%). Eleven patients (36.7%) had evidence of persistent T2E on initial imaging after the embolization procedure; additional follow-up revealed eventual sac stabilization at a mean of 21.3 ± 7.2 months, and therefore, these patients did not require further intervention. In the remaining four cases (13.3%), there was persistent T2E after the initial TLE, requiring a second intervention. Repeat TLE stabilized growth in three of these four patients after a mean of 17.6 ± 12.9 months. One patient required open sacotomy and ligation of lumbar vessels due to continued persistence of the T2E and continued aneurysm growth. There were no ischemic complications related to the embolization procedures. Factors associated with persistent endoleak after initial embolization were larger aneurysm diameter at the time of initial endoleak identification (P < .001) and the use of antiplatelet agents (P < .02). The use of anticoagulation was not a significant risk factor for endoleak recurrence or aneurysm growth after TLE. CONCLUSIONS TLE of T2E is a safe and effective treatment option for T2E with aneurysm growth following EVAR. Patients taking antiplatelet medication and those with larger aneurysms at the time of endoleak identification appear to be at increased risk for persistent endoleak and need for subsequent procedures following initial TLE. These patients may require more intensive monitoring and follow-up.
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Affiliation(s)
- John F Charitable
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Peter I Patalano
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY.
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Ameli-Renani S, Pavlidis V, Morgan RA. Secondary Endoleak Management Following TEVAR and EVAR. Cardiovasc Intervent Radiol 2020; 43:1839-1854. [PMID: 32778905 PMCID: PMC7649162 DOI: 10.1007/s00270-020-02572-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/22/2020] [Indexed: 11/01/2022]
Abstract
Endovascular abdominal and thoracic aortic aneurysm repair and are widely used to treat increasingly complex aneurysms. Secondary endoleaks, defined as those detected more than 30 days after the procedure and after previous negative imaging, remain a challenge for aortic specialists, conferring a need for long-term surveillance and reintervention. Endoleaks are classified on the basis of their anatomic site and aetiology. Type 1 and type 2 endoleaks (EL1 and EL2) are the most common endoleaks necessitating intervention. The management of these requires an understanding of their mechanics, and the risk of sac enlargement and rupture due to increased sac pressure. Endovascular techniques are the main treatment approach to manage secondary endoleaks. However, surgery should be considered where endovascular treatments fail to arrest aneurysm growth. This chapter reviews the aetiology, significance, management strategy and techniques for different endoleak types.
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Affiliation(s)
- Seyed Ameli-Renani
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Vyzantios Pavlidis
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Robert A Morgan
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, UK. .,Vascular & Cardiac Surgery Research Centre, St George's University of London, Cranmer Terrace, London, SW17 ORE, UK.
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Salaskar AL, Razjouyan F, Cho AL, Sood RR, Akman A, Scher D, Venbrux AC, Sarin SN. Single institutional experience of peripheral applications of a liquid embolic agent: Ethylene Vinyl Alcohol Copolymer. CVIR Endovasc 2020; 3:38. [PMID: 32743749 PMCID: PMC7396416 DOI: 10.1186/s42155-020-00117-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 04/03/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of ethylene vinyl alcohol (EVOH) copolymer for the treatment of a variety of peripheral vascular pathologies. RESULTS Between October 2010 and October 2017, 43 patients who underwent total 54 EVOH embolization procedures for the treatment of peripheral vascular pathologies were included. The cases which involved the use of EVOH for the treatment of nonvascular, neurologic, ophthalmologic, otolaryngologic or head-neck pathologies were excluded. The demographic data, technical and clinical success rates, and procedure-related details and complications were obtained. The most common indications for EVOH embolization were type II endoleaks (n = 18) and peripheral arteriovenous malformations (n = 14). The majority of cases (62.5%) used EVOH without any adjunct embolic material. The results of this study showed 100% technical success rates and 89% clinical success rates. No events of nontarget embolization or other procedure-related complications were noted. The mortality & morbidity rates were 0%. The loss to follow up rate was 16% (9 /54). The mean follow-up period was 134 days (range, 30 to 522 days). CONCLUSION The single institutional experience supports the safety and efficacy of EVOH embolization in the treatment of various peripheral vascular conditions.
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Affiliation(s)
- Abhijit L Salaskar
- Division of Vascular and Interventional Radiology, George Washington University Hospital, Washington, DC, 20037, USA.
| | - Faezeh Razjouyan
- Division of Vascular and Interventional Radiology, George Washington University Hospital, Washington, DC, 20037, USA
| | - Alexander L Cho
- Division of Vascular and Interventional Radiology, George Washington University Hospital, Washington, DC, 20037, USA
| | - Rishi R Sood
- Division of Vascular and Interventional Radiology, George Washington University Hospital, Washington, DC, 20037, USA
| | - Andrew Akman
- Division of Vascular and Interventional Radiology, George Washington University Hospital, Washington, DC, 20037, USA
| | - Daniel Scher
- Division of Vascular and Interventional Radiology, George Washington University Hospital, Washington, DC, 20037, USA
| | - Anthony C Venbrux
- Division of Vascular and Interventional Radiology, George Washington University Hospital, Washington, DC, 20037, USA
| | - Shawn N Sarin
- Division of Vascular and Interventional Radiology, George Washington University Hospital, Washington, DC, 20037, USA
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Direct percutaneous embolization of aneurysm sac: a safe and effective procedure to treat post-EVAR type II endoleaks. Radiol Med 2020; 126:258-263. [PMID: 32661779 DOI: 10.1007/s11547-020-01247-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To report safety and effectiveness of type II endoleak embolization, with percutaneous direct aneurysm sac puncture. MATERIALS AND METHODS Fifty patients, 31 male (mean age 55 ± 5), with post-EVAR type-II endoleak underwent direct percutaneous sac puncture for embolization. Procedures were performed, under local anesthesia. Sac puncture was done using a 20G needle under rotational angiography guidance. A coaxial system (4 Fr catheter + 2.7 microcatheter) was used to navigate the sac. During the follow-up period, all patients underwent contrast-enhanced ultrasound (CEUS) at 6 and 12 months. RESULTS Technical success, with complete exclusion of the aneurysm sac, was achieved in all cases. Time of procedure varied between 36 and 68 min (mean 51.36 min). Mean fluoroscopy time was 16.7 min. A posterior left access was used in 41 cases, posterior right access in 6 cases, and an anterior approach in 3. In 19 cases (38%), one or more feeding vessels were visualized and embolized. Sac embolization was done using Onyx plus micro-coils in 31 cases (62%) and Onyx alone in 19 cases (38%). Mean amount of Onyx was 6 ml. No complications, correlated with the direct percutaneous sac puncture, or to Onyx injection occurred. After 1-year follow-up, sac shrinkage occurred in 34 cases (68%), while in 16 patients (32%) sac size remained stable without evidence of sac perfusion. CONCLUSION Percutaneous direct sac embolization using Onyx in combination or not with microcoils represents a safe and valid technique to solve post-EVAR type II endoleaks.
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Transarterial Perigraft Balloon-Assisted Onyx Embolization of Type II Endoleak. J Vasc Interv Radiol 2019; 30:617-619. [PMID: 30910187 DOI: 10.1016/j.jvir.2018.11.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/22/2018] [Accepted: 11/25/2018] [Indexed: 11/22/2022] Open
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Bryce Y, Lam C(K, Ganguli S, Schiro BJ, Cooper K, Cline M, Oklu R, Vatakencherry G, Peña CS, Gandhi RT. Step-by-Step Approach to Management of Type II Endoleaks. Tech Vasc Interv Radiol 2018; 21:188-195. [DOI: 10.1053/j.tvir.2018.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ultee KHJ, Büttner S, Huurman R, Bastos Gonçalves F, Hoeks SE, Bramer WM, Schermerhorn ML, Verhagen HJM. Editor's Choice - Systematic Review and Meta-Analysis of the Outcome of Treatment for Type II Endoleak Following Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2018; 56:794-807. [PMID: 30104089 DOI: 10.1016/j.ejvs.2018.06.009] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 06/06/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The efficacy and need for secondary interventions for type II endoleaks following endovascular abdominal aortic aneurysm repair (EVAR) remain controversial. This systematic review aimed at investigating the clinical outcomes of different type II endoleak treatments in patients with a persistent type II endoleak after EVAR. DATA SOURCES Embase, Medline via Ovid, Web of Science Core Collection, the Cochrane CENTRAL, and Google Scholar. REVIEW METHODS This systematic review was performed in accordance with the PRISMA Statement. Outcomes of interest were technical and clinical success, change in sac diameter, complications, need for additional interventions, abdominal aortic aneurysm (AAA) rupture, and (AAA related) mortality. Meta-analyses were performed with random effects models. RESULTS A total of 59 studies were included, with a cumulative cohort of 1073 patients with persistent type II endoleak. Peri-operative complications following treatment of type II endoleaks occurred in 3.8% of patients (95% CI 2.7-5.2%), and AAA related mortality was 1.8% (95% CI 1.1-2.7%). Overall technical success was 87.9% (95% CI 83.1-92.1%), while clinical success was 68.4% (95% CI 61.2-75.1%). Among studies detailing sac dynamics, decrease or stable sac, with or without resolution, was achieved in 78.4% (95% CI 70.2-85.6%). Changes in sac diameter following type II endoleak treatment were documented in 157 patients to at least 24 months. Within this group an actual decrease in sac diameter was reported in only 27 of 40 patients. CONCLUSION There is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although generally safe, the lack of evidence supporting the efficacy of type II endoleak treatment leads to difficulty in assessing its merits.
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Affiliation(s)
- Klaas H J Ultee
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Stefan Büttner
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Roy Huurman
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Frederico Bastos Gonçalves
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Hospital de Santa Marta, CHLC & NOVA Medical School, Lisbon, Portugal
| | - Sanne E Hoeks
- Department of Anaesthetics, Erasmus University Medical Centre, The Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre and Harvard Medical School, Boston, MA, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
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Standard “off-the-shelf” multibranched thoracoabdominal endograft in urgent and elective patients with single and staged procedures in a multicenter experience. J Vasc Surg 2018; 67:1005-1016. [DOI: 10.1016/j.jvs.2017.08.068] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/01/2017] [Indexed: 11/23/2022]
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Zubair MM, Chinnadurai P, Loh FE, Loh TM, Lumsden AB, Bechara CF. A novel technique combining laparoscopic and endovascular approaches using image fusion guidance for anterior embolization of type II endoleak. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 3:7-10. [PMID: 29349363 PMCID: PMC5757813 DOI: 10.1016/j.jvscit.2016.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 09/15/2016] [Indexed: 11/20/2022]
Abstract
Type II endoleak (T2E) leading to aneurysm sac enlargement is one of the challenging complications associated with endovascular aneurysm repair. Recent guidelines recommend embolization of T2E associated with aneurysmal sac enlargement. Various percutaneous and endovascular techniques have been reported for embolization of T2E. We report a novel technique for T2E embolization combining laparoscopic and endovascular approaches using preoperative image fusion. We believe our technique provides a more direct access to the lumbar feeding vessels that is typically challenging with transarterial or translumbar embolization techniques.
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Affiliation(s)
- M. Mujeeb Zubair
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Tex
| | - Ponraj Chinnadurai
- Angiography Division, Siemens Medical Solutions USA Inc, Hoffman Estates, Ill
| | - Francis E. Loh
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Tex
| | - Thomas M. Loh
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Tex
| | - Alan B. Lumsden
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Tex
| | - Carlos F. Bechara
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Tex
- Correspondence: Carlos F. Bechara, MD, Department of Cardiovascular Surgery, Houston Methodist Hospital, Smith Tower, Ste 1401, 6550 Fannin St, Fl 14, Houston, TX 77030Department of Cardiovascular SurgeryHouston Methodist HospitalSmith TowerSte 14016550 Fannin StFl 14HoustonTX77030
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Zhang X, Sun Y, Chen Z, Jing Y, Xu M. Management of Endovascular Aortic Aneurysm Complications via Retrograde Catheterization Through the Distal Stent-Graft Landing Zone. Vasc Endovascular Surg 2017; 51:390-393. [PMID: 28548006 DOI: 10.1177/1538574417710414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE A retrograde technique through the gap between the distal stent landing zone and the iliac artery wall has been applied to treat type II endoleak after endovascular aortic aneurysm repair (EVAR). In this study, we tried to investigate its efficacy in the management of type III endoleak and intraoperative accidental events. METHODS We reported 2 complications of EVAR that were difficult to treat with conventional methods. One patient had a sustained type III endoleak after EVAR, and the right renal artery was accidentally sealed by a graft stent in the other patient during the operation. RESULTS Both complications were managed by the retrograde technique from the distal stent landing zone. In the first case, the endoleak was easily embolized by the retrograde catheterization technique, and in the second case, a stent was implanted in the right renal artery using the retrograde technique to restore blood flow. CONCLUSION In some EVAR cases, the technique of retrograde catheterization through the distal stent-graft landing zone is feasible, safe, and easy to perform.
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Affiliation(s)
- Xicheng Zhang
- 1 Department of Vascular Surgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuan Sun
- 1 Department of Vascular Surgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Zhaolei Chen
- 1 Department of Vascular Surgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuanhu Jing
- 1 Department of Vascular Surgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Miao Xu
- 1 Department of Vascular Surgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
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Iliac Limb Perigraft Access with Robotic Catheter Assistance for Type 2 Endoleak Embolization. Ann Vasc Surg 2016; 38:317.e5-317.e7. [PMID: 27531089 DOI: 10.1016/j.avsg.2016.05.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/10/2016] [Accepted: 05/14/2016] [Indexed: 11/24/2022]
Abstract
Retrograde perigraft access to the aneurysmal sac for type 2 endoleak embolization is a relevant alternative to standard transarterial and translumbar approaches. Entering the space between the graft and the iliac artery requires support and pushability, and might be challenging with standard endovascular catheters. We describe the case of a 78-year-old woman with an enlarging aneurysm due to type 2 endoleak, 3 years after EVAR. Despite multiple attempts at manual catheterization, we were unable to engage the space between the iliac wall and the stent graft. The assistance of a robotic catheter allowed for precise positioning of the wire and catheter, maximizing pushability. This permitted fast wire access to the perigraft space and facilitated catheter progress to the sac expeditiously. Endovascular robotic catheter assistance allows optimal support for such retrograde perigraft navigation for type 2 endoleak embolization.
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Ciampi Dopazo JJ, Gastaldo F, Lanciego Pérez C. Unusual approach for the treatment of a type II endoleak. RADIOLOGIA 2016; 58:235-8. [PMID: 26908248 DOI: 10.1016/j.rx.2015.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 10/22/2015] [Accepted: 12/08/2015] [Indexed: 11/24/2022]
Abstract
This case presentation is about an 88 years-old male patient with previous endovascular aortic aneurysm repairment history and aortic endoleak type II (EL2). The direct lumbar artery catheterization was considered an alternative to solve EL2, associated with aortic endovascular prosthesis and due to an incomplete sealing or exclusion of the aneurysmal sac or a vascular segment demonstrated by imaging studies, when other treatment alternative failed (transarterial embolization) to control the aneurysm growing. Performing translumbar approach was decided by puncturing the artery lumbar (L4) left, previously the lumbar arteries (L4) were evaluated in the abdominal CT arterial phase to guide a puncture/access under flouroscopy control. Diagnostic angiogram clearly demonstrated the median sacral and right lumbar arteries inflow into the aneurysm sac. Transcatheter embolization with fibered platinum microcoils was performed of the median sacral artery and lumbar left and right arteries (L4), showing satisfactory endoleak devascularization.
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Affiliation(s)
- J J Ciampi Dopazo
- Departamento de Radiología, Sección de Radiología Intervencionista, Complejo Hospitalario de Toledo, Toledo, España.
| | - F Gastaldo
- Deparment of Radiology, Interventional Radiology, McMaster University, Hamilton, Ontario, Canada
| | - C Lanciego Pérez
- Departamento de Radiología, Sección de Radiología Intervencionista, Complejo Hospitalario de Toledo, Toledo, España
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Lu W, Fu W, Si Y, Chen X, Cai Q, Xiong Y, Hong S, Yang D. A novel endovascular occlusion device with a steerable introducer for embolization in a porcine model. Catheter Cardiovasc Interv 2015; 87:E86-96. [PMID: 26651031 DOI: 10.1002/ccd.26312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/09/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Weifeng Lu
- Department of Vascular Surgery; Zhongshan Hospital of Xiamen University; Xiamen China
| | - Weiguo Fu
- Department of Vascular Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Yi Si
- Department of Cardiovascular Surgery; Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine; Shanghai China
| | - Xiaoli Chen
- Cancer Research Center, Medical College of Xiamen University; Xiamen China
| | - Qiuni Cai
- Department of Vascular Surgery; Zhongshan Hospital of Xiamen University; Xiamen China
| | - Yu Xiong
- Department of Hepatobiliary Surgery; Zhongshan Hospital of Xiamen University; Xiamen China
| | - Shichai Hong
- Department of Vascular Surgery; Zhongshan Hospital of Xiamen University; Xiamen China
| | - Donghai Yang
- Department of Vascular Surgery; Zhongshan Hospital of Xiamen University; Xiamen China
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Giles KA, Fillinger MF, De Martino RR, Hoel AW, Powell RJ, Walsh DB. Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair. J Vasc Surg 2015; 61:1129-36. [DOI: 10.1016/j.jvs.2014.12.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 12/01/2014] [Indexed: 11/26/2022]
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Hajibandeh S, Ahmad N, Antoniou GA, Torella F. Is intervention better than surveillance in patients with type 2 endoleak post-endovascular abdominal aortic aneurysm repair? Interact Cardiovasc Thorac Surg 2014; 20:128-34. [PMID: 25301297 DOI: 10.1093/icvts/ivu335] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether, in patients with persistent type 2 endoleak (T2EL) post-endovascular abdominal aortic aneurysm repair (EVAR), intervention is associated with better outcomes than observation. Four hundred and eighty-three papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In a recently published systematic review including 21 744 patients who underwent EVAR, 35.4% of T2ELs resolved spontaneously, 28.5% of secondary interventions were unsuccessful and rupture occurred in only 0.9% of patients with isolated T2EL. Spontaneous sealing in 62-75% of T2ELs were reported by two included studies. A failure rate of 80% associated with transarterial embolization in aggressive treatment of any T2EL was reported by one study. Conversely, another study reported a clinical success rate of 80% associated with the transarterial approach. One study reported that of patients who underwent embolization of a persistent T2EL, 37.9% continued to experience sac growth and 20% had recurrent endoleak at 5 years. One study demonstrated that the transealing procedure for T2EL had a technical success rate of 94.1%. We conclude that the available evidence with regard to management of persistent T2EL is mainly based on retrospective case series. Conflicting results from heterogeneous studies, however, failed to support an optimal threshold for intervention. Considering the reported relatively benign natural course of most T2ELs and the fact that most T2ELs seal spontaneously, conservative management of persistent T2EL in the absence of sac expansion might be appropriate. Where intervention is indicated, imaging should exclude occult type I and III leaks as ∼25% are not simple T2EL. Translumbar embolization of T2EL is associated with higher success rates than transarterial. Following a successful intervention, continued long-term surveillance is necessary due to the high risk (25-80%) of recurrence. The current evidence indicates that aneurysmal rupture due to an isolated T2EL is rare. Long-term prospective studies may provide better evidence to define the optimal threshold for intervention.
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Affiliation(s)
- Shahin Hajibandeh
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Naseer Ahmad
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - George A Antoniou
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
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Chung R, Morgan RA. Type 2 Endoleaks Post-EVAR: Current Evidence for Rupture Risk, Intervention and Outcomes of Treatment. Cardiovasc Intervent Radiol 2014; 38:507-22. [PMID: 25189665 DOI: 10.1007/s00270-014-0987-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022]
Abstract
Type 2 endoleaks (EL2) are the most commonly encountered endoleaks following EVAR. Despite two decades of experience, there remains considerable variation in the management of EL2 with controversies ranging from if to treat, when to treat and how to treat. Here, we summarise the available evidence, describe the treatment techniques available and offer guidelines for management.
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Affiliation(s)
- Raymond Chung
- Radiology, Ground Floor, St. James Wing, St. George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, England, UK,
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