Abstract
Introduction: The aim of the present study is to report the outcome of patients presenting an isolated type II endoleak (TIIEL) requiring reintervention and to identify clinical and anatomical characteristics potentially implicated in refractory TIIEL occurrence and fate. Materials and Methods: A multicenter retrospective study on TIIEL requiring reintervention was conducted between January 2003 and December 2020. Demographic and clinical characteristics, procedural technical aspects, reinterventions, and outcomes were recorded. TIIEL determining sac expansion greater than 10 mm underwent a further endovascular procedure aiming to exclude aneurismal sac. Redo endovascular procedures were performed via endoleak nidus direct embolization and/or aortic side branches occlusion. TIIELs responsible for persisting aneurysmal sac perfusion 6 months after redo endovascular procedures were classified as “refractory” and submitted to open conversion. Results: A total of 102 TIIEL requiring reintervention were included in the final analysis. Eighty-eight (86.27%) patients were male, the mean age was 77.32 ± 8.08 years, and in 72.55% of cases the American Society of Anaesthesiologists (ASA) class was ≥3. The mean aortic diameter was 64.7 ± 14.02 mm, half of treated patients had a patent inferior mesenteric artery (IMA), and 44.11% ≥ 3 couples of patent lumbar arteries (LA). In 49 cases (48.03%) standard endovascular aneurysm repair (EVAR) procedure was completed without adjunctive maneuvers. All enrolled patients were initially submitted to a further endovascular procedure once TIIEL requiring reintervention was diagnosed; 57 patients underwent LAs or IMA embolization (55.87%), 42 transarterial aneurismal sac embolization (41.17%), and three (2.96%) laparoscopic ostial ligations of the inferior mesenteric artery. During a mean follow-up of 15.22 ± 7.57 months (7–48), a redo endovascular approach was able to ensure complete sac exclusion in 52 cases, while 50 patients presented a still evident refractory TIIEL and therefore a surgical conversion or semiconversion was conducted. At the univariate analysis refractory TIIEL patients were significantly different from those who did not develop the complication in terms of preoperative clinical, morphological characteristics, and initial EVAR procedures: coronary artery disease occurrence (p = 0.005, OR: 3.18, CI95%: 1.3–7.2); preoperative abdominal aortic aneurysm (AAA) sac diameter (p = 0.0055); IMA patency (p = 0.016, OR: 2.64, CI95%: 1.18–5.90); three or more patent LAs; isolated standard EVAR without adjunctive procedures (p > 0.0001; OR: 9.48, CI95%: 3.84–23.4). Conclusions: Our experience seems to demonstrate that it is reasonable to try to preoperatively identify those patients who will develop a refractory TIIEL after EVAR and those with a TIIEL requiring reintervention for whom a simple endovascular redo will not be enough, needing surgical conversion.
Highlights
Endovascular aneurysms repair (EVAR) has been widely accepted as the procedure of choice for patients with infrarenal abdominal aortic aneurysm (AAA) in suitable and in complex anatomies [1].EVAR still presents the concern of frequent reinterventions for long-term complications, primarily endoleaks [2,3,4,5,6,7]
Sac expansion of more than 5 mm has been reported to be associated with AAA rupture after EVAR [11], a recent review showed that almost 30% of patients with type II endoleak (TIIEL) evolving towards rupture do not have any documented sac expansion
The aim of the present study is to report the outcome of patients presenting an isolated type II endoleak (TIIEL) that requires reintervention and to identify clinical and anatomical characteristics potentially implicated in refractory TIIEL occurrence and fate
Summary
EVAR still presents the concern of frequent reinterventions for long-term complications, primarily endoleaks [2,3,4,5,6,7]. Type 2 endoleak (TIIEL) is the most reported cause of reintervention after standard EVAR [8]. TIIEL, defined by the persistent perfusion of the aneurysmal sac after EVAR by side branches, such as lumbar arteries (LAs) and/or the inferior mesenteric artery (IMA), presents a variable incidence that can be as high as 40% [9]. Sac expansion of more than 5 mm has been reported to be associated with AAA rupture after EVAR [11], a recent review showed that almost 30% of patients with TIIEL evolving towards rupture do not have any documented sac expansion
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