Systematic Review and Meta-Analysis of the Outcome of Different Treatments for Type 1a Endoleak After EVAR

Abstract

Insufficient evidence is available to recommend a particular strategy for the treatment of type 1a endoleaks (T1aELs) after endovascular abdominal aneurysm repair (EVAR). The aim of this study was to report outcomes of the different treatment modalities proposed for persistent and late-occurring T1aEL after EVAR. A systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library) was undertaken until August 2018. Studies about treatment of T1aEL after EVAR (excluding intraoperative treatments during the first EVAR) presenting a series of 5 or more patients with extractable outcome data (at least intraoperative and/or early results) were included. Meta-analyses of proportions were performed using a random-effects model. A total of 39 nonrandomized studies were included (714 patients; 88.1% males, 95% confidence interval [CI] 84.5-91.7; weighted mean age 75.76years, 95% CI 74.11-77.4). Overall estimated technical success (TS) and clinical success (CS) rates were 93.2% (95% CI 90.5-95.8) and 88.2% (95% CI 84.5-91.9), respectively. Two hundred eighteen patients underwent proximal extension (98.1% TS, 95% CI 96.3-99.8), 131 chimney EVAR (93.9% TS, 95% CI 89.9-97.9), 97 fenestrated EVAR (86.2% TS, 95% CI 77.3-95.1), 90 open conversion (96.5% TS, 95% CI 93-100), 71 embolization (95.2% TS, 95% CI 90.4-100), 35 endostapling (57.2% TS, 95% CI 14.1-100), and 72 conservative treatment (75.4% CS, 95% CI 56.4-94.5). Estimated overall 30-day mortality was 3.2% (95% CI 1.7-4.7), and it was higher for patients undergoing open surgery (6.6%, 95% CI 1.7-11.5). Overall, endoleak resolution during the mean follow-up of 19.4months (95% CI 15.45-23.36) was maintained in 91% of the patients (95% CI 87.7-94.3). T1aEL repair appeared generally feasible, with good early to midterm outcomes. Different treatments are available, and the choice should be based on endoleak characteristics, aortic anatomy, and the patient's surgical risk. Conservative treatment and endoleak embolization should be considered only in selected cases, such as low-flow endoleaks and unfit patients.