Results of Transarterial Embolization for Treating Type 2 Endoleaks: A Single-Center Experience

Videolaparoscopic-Guided Saccography and Direct Sac Embolization After Standard EVAR

INTRODUCTION

The occurrence of type II endoleak (T2EL) presents a significant challenge in standard endovascular aneurysm repair (EVAR), with ongoing debate in the literature regarding its optimal management. Although spontaneous resolution has been observed in many cases, intervention is often required to prevent progressive sac enlargement and rupture. Various approaches have been described, including translumbar, transarterial, and transcaval embolization, as well as direct sac puncture. The aim of this study is to evaluate the role of videolaparoscopic-guided saccography and direct sac embolization (ViSE) in patients with sac enlargement following EVAR.

METHODS

A prospectively maintained registry of patients undergoing standard EVAR between 2016 and 2022 at our institution was retrospectively reviewed. Exclusion criteria included concomitant computed tomography (CT)-diagnosed type I endoleak or type III endoleak (T1EL or T3EL), less than 6 months of follow-up, or no available imaging study for review. A nidus posterior to the main body of endograft and a hostile abdomen (severe obesity body mass index [BMI] >35 kg/m2, previous open surgery, or history of peritonitis) were considered contraindications to ViSE.

RESULTS

A total of 259 standard EVAR procedures were performed during the study period, with 63 patients (24.3%) identified as having T2EL, 26 underwent endovascular treatment for significant sac growth during follow-up; 14 of these patients received ViSE (5.4%) and were included in the study. The median procedure time and median fluoroscopic time were 140 (interquartile range [IQR]=105-150) and 40.5 (IQR=31-45) minutes, respectively. Technical success was achieved in 12 of 14 patients (87%). In 7 patients (50%), the inferior mesenteric artery (IMA) was ligated. An occult T1EL or T3EL endoleak was revealed in 5 patients (35%), requiring an immediate or staged adjunct procedure. After a median follow-up of 32.4 months (IQR=25.3-51.7), 2 patients presented sac growth and required surgical conversion. None of the patients died due to aortic-related causes.

CONCLUSION

Videolaparoscopic-guided saccography and direct sac embolization may be considered a valid alternative in patients with T2EL and sac growth. In our early experience, it has proven to be safe and effective in treating the nidus and IMA, and identifying hidden T1EL or T3EL.

CLINICAL IMPACT

Videolaparoscopic-guided saccography and direct sac embolization (ViSE) represent a valuable option for managing type II endoleak (T2EL) with sac enlargement after EVAR. This approach allows precise treatment of the nidus and the inferior mesenteric artery while also identifying undetected type I and III endoleaks that may require further intervention. By integrating ViSE into clinical practice, physicians can improve diagnostic accuracy and expand treatment strategies for complex endoleak cases. The technique enhances endovascular options, potentially reducing the need for open conversion and improving long-term outcomes in patients with persistent sac growth.

Technical and clinical success analysis of transarterial embolization therapy in type II endoleaks following endovascular aortic repair

This single-center study investigated the safety and efficacy of transarterial embolization of type II endoleaks for expanding aneurysm sacs following endovascular aortic repair (EVAR).36 patients (33 men, 75.9±6.6 years) underwent a total of 50 endovascular procedures for type II endoleak embolization between 2008 and 2023. Analyses included the assessment of patient risk profiles, aneurysm morphology, and endoleak characteristics. Outcome parameters comprised the technical success (i.e., complete lack of blood flow in the previously perfused aneurysm sac) and complication rates, while clinical success was defined as the absence of endoleak persistence or recurrence and freedom from aneurysm enlargement > 0.5 cm over the follow-up period.Transarterial embolization was technically successful in 84% of procedures with a complication rate of 2%. Most interventions were coil-based (72%), while a small number relied solely on liquid embolic agents (14%). Absence of a persisting endoleak in the earliest follow-up could be demonstrated in 75.6% of cases, whereas the absence rate for endoleak recurrence was substantially lower (46.3%). No aneurysm enlargement > 0.5 cm during follow-up was ascertained after 73.2% of interventions.Transarterial embolization represents a safe treatment for type II endoleaks after EVAR. While embolization was moderately effective in preventing further expansion of aneurysms due to endoleak recurrence, most procedures were successful in permanently eliminating the targeted feeder vessels. · Transarterial embolization of type II endoleaks has a high technical success rate.. · The emergence of new feeder vessels may necessitate multiple procedures over time.. · Patient risk profiles did not factor into the clinical outcome.. · Krompaß K, Grunz JP, Augustin AM et al. Technical and clinical success analysis of transarterial embolization therapy in type II endoleaks following endovascular aortic repair. Fortschr Röntgenstr 2024; DOI 10.1055/a-2384-4601.

CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair

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.

Factors Influencing Compliance to Follow-Up After Endovascular Aneurysm Repair

OBJECTIVES

Regular follow-up after endovascular repair of aortic aneurysm is necessary to detect endoleak and/or migration of the stentgraft. However, absence or incomplete compliance to follow-up is common in this patient population. In this study we will analyse the frequency of non-compliance to post-EVAR follow-up and explore the underlying reasons.

METHODS

All patients undergoing EVAR for infrarenal aortic aneurysm between 1st January 2011 and 31st December 2020 were included in this retrospective study. Absence of compliance to FU was defined as not showing up at the out-patient clinic; incomplete FU was defined as a surveillance gap of >18 months.

RESULTS AND CONCLUSION

Non-compliance to follow-up was 35.9% (175 patients). In the multivariate analysis the patients who came with a ruptured aneurysm and patients who needed secondary therapy in the first 30 days more often did not comply with the FU protocol (P = .03 and P < .01). Other studies have confirmed the low attendance to follow-up after EVAR.

Midterm Outcomes of Endoleak Type 2 Embolization after Endovascular Aortic Aneurysm Repair Using a Neurointerventional Approach

BACKGROUND

Type 2 endoleaks (T2ELs) have been considered a benign condition and intervention is recommended when they are associated to sac expansion. The aim of this study was to report on T2EL embolization midterm outcomes, using neurointerventional material.

METHODS

A single-center retrospective analysis of consecutive patients treated with transarterial embolization, using neurointerventional material, for T2EL after standard endovascular aortic aneurysm repair (EVAR) between January 01, 2017 and July 30, 2022, was undertaken. Primary outcome was technical success and secondary outcome was T2EL recurrence during follow-up.

RESULTS

Twenty six patients [92.3% males, mean age 73.9 ± 7.7 years] were included. The median time between EVAR and T2EL diagnosis was 12 months (range: 1-84 months). In 38.5% of patients, T2EL was detected at first month after EVAR. The time to embolization was 18 months (range: 1-96 months). In 42.3% of cases, a patent inferior mesenteric artery was suspected to relate to T2EL formation while in 42.3% of cases, a lumbar artery. Twelve procedures (38.4%) were performed using coils and Onyx and 13 (50%), using only Onyx. Technical success was 84.6%. The mean follow-up was 24 months (range: 1-60 months), including 20 patients. In 30% of cases, an T2EL recurrence was detected. Three patients (11.5%) underwent secondary embolization.

CONCLUSIONS

Transarterial embolization for T2EL, using neurointerventional material, provided acceptable technical success and T2EL recurrence rates at 2 years of follow-up. Longer follow-up data would further estimate the durability of the technique.