A meta-analysis of translumbar embolization versus transarterial embolization for type II endoleak after endovascular repair of abdominal aortic aneurysm

Understanding Type II Endoleak: A Harmless Imaging Finding or a Silent Threat?

Type II endoleak (T2EL) represents a challenging clinical entity following endovascular abdominal aortic aneurysm repair (EVAR). Although several studies have suggested that T2ELs are related to an increased risk of aneurysm sac growth and subsequent rupture, the exact role that T2ELs play in long-term outcomes remains debatable. Understanding the pathophysiology, diagnostic modalities, and management options of T2ELs is important for patients' safety and proper resource utilization. While conservative management may be suitable for asymptomatic patients with a stable aneurysm size, interventional approaches, including transarterial embolization, direct sac puncture embolization and open conversion have been described for patients with persistent T2EL associated with sac expansion. However, more research is needed to better determine the clinical benefit of such interventions. A thorough evaluation of all endoleak types before T2EL treatment would be reasonable for patients with T2ELs associated with sac expansion. Further studies are needed to refine treatment strategies aimed at minimizing T2EL-related complications. Collaborative efforts among vascular specialists, radiologists, and researchers are of paramount importance to address this ongoing clinical challenge.

Early and Mid-Term Outcomes of Transcaval Embolization for Type 2 Endoleak after Endovascular Aortic Repair

Background: Among the endovascular approaches for the management of endoleak type 2 (EL 2), transcaval embolization (TCE) has shown encouraging outcomes. However, the literature is still limited. This study aimed to present the early and mid-term outcomes of TCE for EL 2 after endovascular aortic repair. Methods: A retrospective, single-center analysis of consecutive patients managed with TCE for EL 2 after standard or complex endovascular aortic repair, from August 2015 to March 2024, was conducted. The indication for TCE was the presence of an EL 2 related to ≥5 mm sac increase, compared to the first imaging after aneurysm exclusion or the smallest diameter during follow-up. Patients managed with TCE for other types of endoleaks were excluded. The primary outcomes were technical and clinical successes during follow-up. Results: Forty-three patients were included (mean age: 75.1 ± 6.0 years, 90.7% males). Technical success was 97.7%. Selective embolization was performed in 48.8% and non-selective in 51.2%. No death was recorded at 30 days. The estimated clinical success was 90.0% (standard error; SE: 6.7%) and the freedom from EL 2 was 89.0% (SE 6.4%) at 36 months. Cox regression analysis showed that the type of embolization (selective vs. non-selective), type of previous repair (f/bEVAR vs. EVAR), and use of anticoagulants did not affect follow-up outcomes. Reinterventions related to EL 2 were performed in 12.5%; three underwent an open conversion. Conclusions: TCE was related to high technical success and limited peri-operative morbidity, regardless of the type of initial endovascular aortic repair. Clinical success was encouraging with reinterventions for EL 2 affecting 12.5% of patients.

Direct sac puncture versus transarterial embolization of type II endoleaks after endovascular abdominal aortic aneurysm repair: Comparison of outcomes

PURPOSE

Type 2 endoleak (T2EL) is the most common type of endoleak after endovascular abdominal aortic aneurysm repair (EVAR), and increases the risk of aneurysm sac rupture if it persists beyond 6 months. The purpose of this study is to compare the efficacy and safety of direct sac puncture versus transarterial embolization of T2ELs.

METHODS

Retrospective review of 42 consecutive T2EL embolization procedures, 19 by DSP and 23 by transarterial technique, between January 2015 and December 2020. Primary outcome was aneurysm sac stability and resolution of endoleak at follow-up imaging. Adverse events (AE) were classified based on the Society of Interventional Radiology (SIR) practice guidelines.

RESULTS

Technical success was 94.7% (18/19) in the DSP group and 86.9% (20/23) in the transarterial group (p = 0.32 (-0.77-0.25)). Treatment efficacy was evaluated in 16 patients in the DSP group and 18 patients in the transarterial group who had follow-up imaging ≥6 months after embolization. Mean imaging follow-up was 17.1 ± 11.2 (range, 6-41) months in the DSP group and 26.5 ± 15.4 (range, 6-48) months in the transarterial group (p = 0.06, -19.24-0.37). Treatment efficacy was 75% (12/16) in the DSP group and 33.3% (6/18) in the transarterial group (p = 0.02, 95% CI, 0.09-0.97). There was no procedure-related mortality. Moderate-severe AE occurred in 15.7% (3/19) in the DSP group and 8.7% (2/23) in the transarterial group (p = 0.44, -0.12-0.26).

CONCLUSION

In this study, DSP embolization of T2EL was equally safe and more effective than transarterial embolization in achieving aneurysm sac stability and resolution of endoleak.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

[Secondary ruptures of an abdominal aortic aneurysm treated with a physician-modified fenestrated endograft, endoanchors and finally with open repair]

Secondary rupture is a late complication of endovascular aneurysm repair (EVAR). Open surgery is a technically feasible treatment option in most cases, however, late conversion carries a significant risk of morbidity and mortality, as it usually requires at least partial explantation of the in situ device, which is of major concern especially if suprarenal fixation is present. Endovascular treatment of these cases is usually challenging, especially since the custom-made devices that are often needed are not readily available but having a production time of several weeks. To overcome this limitation, physician-modified stent grafts are getting accepted to treat such urgent cases. We present the case of a patient receiving EVAR who later experienced two ruptures, treated first with a physician-modified endograft and adjunctive endoanchoring, later with open ligation of the lumbar arteries. Orv Hetil. 2023; 164(36): 1426-1431.

Patent iliolumbar artery increase no risk of type II endoleaks after endovascular abdominal aortic aneurysm: a case-control study

Objective

The aims of the present study were to explore the risk factors for type 2 endoleaks (T2ELs) after endovascular aneurysm repair (EVAR) and the association between T2ELs and the iliolumbar artery.

Materials and methods

A single-center, retrospective case-control study in West China Hospital was conducted among patients with infrarenal abdominal aortic aneurysm (AAA) who underwent EVAR between June 2010 and June 2019. The associations of patient characteristics, anatomical factors, internal iliac artery embolization, and ILA with the primary outcome were analyzed. The secondary objective was to analyze survival and reintervention between the T2EL group and the non-T2EL group. Kaplan-Meier survival, propensity matching analysis and multivariate logistic regression analysis were used.

Results

A total of 603 patients were included. The median follow-up was 51 months (range 5.0-106.0). There was a significant difference in the diameter of the lumbar artery (LA), middle sacral artery (MSA) and inferior mesentery artery (IMA), proportion of thrombus and LA numbers. The univariate analysis showed that T2ELs were more likely to develop more thrombus in aneurysm cavity (OR = 0.294, p = 0.012), larger MSA (OR = 1.284, p = 0.04), LA (OR = 1.520, p = 0.015), IMA (OR = 1.056, p < 0.001) and more LAs (OR = 1.390, p = 0.019). The multivariate analysis showed that the number of LAs (HR: 1.349, 95% CI: 1.140-1.595, p < .001) and the diameter of the IMA (HR: 1.328, 95% CI: 1.078-1.636, p = 0.008) were significantly associated with T2ELs. There were no new findings from the propensity score matching. The reintervention-free survival rates were significantly different between the two groups (p = 0.048). Overall survival and AAA-related death rates were not different between the two group. This was consistent with the PSM analysis.

Conclusion

The iliolumbar artery and the different internal iliac artery interventions may not increase the incidence of T2ELs. But the numbers of LAs and IMA diameter were independent risk factors for T2Els. T2ELs was associated with the reintervention but did not affect long-term survival or increase aneurysm-related mortality after EVAR.

Translumbar type II endoleak embolization with a new liquid iodinated polyvinyl alcohol polymer: Case series and review of current literature

Purpose

To describe our experience with the use of a novel iodized Polyvinyl Alcohol Polymer liquid agent (Easyx) in type II endoleak treatment with translumbar approach.

Methods

Our case series is a retrospective review of patients with type II endoleak (T2E) treated with Easyx from December 2017 to December 2020. Indication for treatment was a persistent T2E with an increasing aneurysm sac ≥5 mm on computed tomography angiography (CTA) over a 6-month interval. Technical success was defined as the embolization of the endoleak nidus with reduction or elimination of the T2E on sequent CTA evaluation. Clinical success was defined as an unchanged or decreased aneurysm sac on follow-up CTA. Secondary endpoints included the presence of artifacts in the postprocedural cross-sectional tomographic imaging and post and intraprocedural complications.

Results

Ten patients were included in our retrospective analysis. All T2E were successfully embolized. Clinical success was achieved in 9 out of 10 patients (90%). The mean follow-up was 14 3-20 months. No beam hardening artifact was observed in follow-up CT providing unaltered imaging.

Conclusion

Easyx is a novel liquid embolic agent with lava-like characteristics and unaltered visibility on subsequent CT examinations. In our initial experience, Easyx showed to have all the efficacy requisites to be an embolization agent for type II EL management. Its efficacy, however, should be evaluated in more extensive studies and eventually compared with other agents.

Pre-Emptive Embolization of the Aneurysm Sac or Aortic Side Branches in Endovascular Aneurysm Repair: Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

BACKGROUND

To investigate outcomes of pre-emptive embolization of the aneurysm sac or aortic side branches in endovascular aneurysm repair (EVAR).

METHODS

The review was reported as per Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 with a preregistered protocol. Bibliographic sources (MEDLINE, Embase, and CENTRAL) were searched using subject headings and free text terms. Randomized controlled trials comparing EVAR with versus without embolization were included. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI) applying the Mantel-Haenszel method. Continuous outcomes were summarized using mean difference (MD) and 95% CI applying the inverse variance method. The certainty of evidence was appraised with the Grading of Recommendations Assessment, Development, and Evaluation framework. Version 2 of the Cochrane tool was used to assess the risk of bias. Trial sequential analysis assumed alpha = 5% and power = 80%.

RESULTS

Four randomized controlled trials were included. No significant difference was found in aneurysm-related mortality (RD 0.00, 95% CI -0.03 to 0.03), overall mortality (OR 1.85, 95% CI 0.42-8.13), aneurysm rupture (RD 0.00, 95% CI -0.03 to 0.03), type II endoleak-related reintervention (RD -0.07, 95% CI -0.21 to 0.06), procedure time (MD 20.12, 95% CI -11.54 to 51.77), or fluoroscopy time (MD 11.17, 95% CI -11.22 to 33.56). Patients with pre-emptive embolization had significantly lower odds of type II endoleak (OR 0.45, 95% CI 0.26-0.78) and sac expansion (OR 0.19, 95% CI 0.07-0.52). The risk of bias was high for all outcomes. The certainty of evidence was very low for all outcomes, except for type II endoleak, for which it was low. Trial sequential analysis showed an inconclusive result for overall mortality and type II endoleak-related reintervention but confirmed the advantage of embolization in reducing type II endoleak and sac expansion.

CONCLUSIONS

Limited, low certainty data suggest pre-emptive embolization confers no clinical benefits in 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.

Pilot Animal Study on Robotic-Assisted Endovascular Visceral Interventions

Purpose

To evaluate technical feasibility and safety of common endovascular visceral interventions using a vascular robotic platform through preclinical study.

Material and Methods

The CorPath GRX Robotic System (Corindus Inc, Waltham, Massachusetts) was tested in an anesthetized pig for its ability to navigate various commercially available devices in the abdominal vasculature and to perform routine endovascular visceral procedures. After manually placing a guiding catheter in the celiac trunk, several visceral branches were probed with microcatheters and -wires under robotic assistance, and embolization with liquids (lipiodol), detachable coils and plugs were performed. Furthermore, the origin of the celiac trunk was stented before accessing the left hypogastric artery for pelvic embolization.

Results

All procedures were performed with technical success and without any complications. Navigating the catheters and wires via the steering console proved intuitive. Coil, plug and stent deployment were exclusively controlled by remote with remarkable precision and stability.

Conclusion

Robotic-assisted visceral embolization and stenting as well as pelvic embolization using the CorPath GRX System is feasible and safe. Application of the platform in the abdominal vasculature is demonstrated for the first time. Considering the precision and the potential for reducing the operator’s radiation exposure, further research in this area is highly encouraged to enable translation into clinical practice.

[Endoleaks in endovacular treatment of infrareneral abdominal aortic aneurysm (part I)]

We analyzed the PubMed, Scopus databases and the eLIBRARY electronic library regarding appropriate literature data. In the first part, modern classifications of endoleaks type 1 and 2 after stenting of infrarenal aortic aneurysm are considered. We described causes, risk factors and effectiveness of various treatment options.

Injectable Hydrogel Capable of In Situ Covalent Crosslinking for Permanent Embolization

Vascular embolization provides an effective approach for the treatment of hemorrhage, aneurysms, and other vascular abnormalities. However, current embolic materials, such as metallic coils and liquid embolic agents, are limited by their inability to provide safe, consistent, and controlled embolization. Here, we report an injectable hydrogel that can remain at the injection site and subsequently undergo in situ covalent crosslinking, leading to the formation of a dual-crosslinking network (DCN) hydrogel for endovascular embolization. The DCN hydrogel is simple to prepare, easy to deploy via needles and catheters, and mechanically stable at the target injection site, thereby avoiding embolization of nontarget vessels. It possesses efficient hemostatic activity and good biocompatibility. The DCN hydrogel is also clearly visible under X-ray imaging, thereby allowing for targeted embolization. In vivo tests in a rabbit artery model demonstrates that the DCN hydrogel is effective in achieving immediate embolization of the target artery with long-term occlusion by inducing luminal fibrosis. Collectively, the DCN hydrogel provides a viable, biocompatible, and cost-effective alternative to existing embolic materials with clinical translation potential for endovascular embolization.

A systematic review of the current status of interventions for type II endoleak after EVAR for abdominal aortic aneurysms

OBJECTIVE

To study the mid- and long-term outcomes of type II endoleak treatment after EVAR and the technical aspects of different techniques to exclude endoleaks which different embolic agents.

METHODS

A systematic review was performed using the approach recommended by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for meta-analyses of interventional studies. The comprehensive search was conducted using the following database: MEDLINE, EMBASE, and the Cochrane Library. Patient characteristic, intervention approaches, embolic agents, and results at mid and long term follow up were studied.

RESULTS

A total of 6 studies corresponding to a total of 141 patients fulfilled the inclusion criteria with a mean age of 73-78.6 years and a mean duration of follow up varying from 25 to 42 months. There were different techniques for embolization used (translumbar, transarterial, and transcaval approach) with various types of embolic agents. In all studies, the indication for embolization of the type II endoleaks was sac enlargement of more than 5 mm. A wide range of technical success rate was reported regardless of the intervention strategy being used (17,6%-100%). The overall technical success rate of all studies was 62%.

CONCLUSION

This systematic review shows that there is a wide variety of techniques to exclude a persistent type II endoleak. Different kinds of embolic agents have be used. Due to a lack of peer reviewed data on longterm follow-up, it was not possible to come to recommendations what treatment would be the best for a durable exclusion of a persistent type II endoleak after an initially successful EVAR. There remains an urgent need for proper executed studies, either randomized or with close observation in relation to longer follow-up.

Outcomes of transcaval endoleak embolization via laser fenestration of the inferior vena cava following endovascular abdominal aortic aneurysm repair

This report describes a single center experience with laser fenestration of the inferior vena cava for the treatment of type 2 endoleak after endovascular abdominal aortic aneurysm repair. Our technique is reviewed, and clinical data after treatment are reported. Twelve patients underwent transcaval embolization via laser fenestration. Technical success was achieved in all cases (100%) with no postoperative complications. At a median follow-up of 12.9 months, no patient demonstrated a persistent endoleak and there were no cases of aortocaval fistula. Transcaval embolization, via laser fenestration, provides an additional strategy for the management of type 2 endoleak after endovascular abdominal aortic aneurysm repair.

Embolization of Type 2 Endoleaks in the Abdominal Aorta Using Ethylene Vinyl Alcohol Copolymer

BACKGROUND

 Type 2 endoleaks (T2EL) are the most frequent complication following endovascular aortic repair. Multiple studies primarily deal with the technical and clinical success of the embolization of persisting T2EL, thereby revealing controversial outcomes. Current reports rarely focus on the detailed execution of such a complex interventional procedure with respect to the difficult anatomic setting.

METHODS

 The present review provides an in-depth depiction and evaluation of the interventional methodology of the embolization of T2EL in the abdominal aorta with use of ethylene vinyl alcohol copolymer (EVOH). Complicating anatomic conditions are taken into account as well as technical and clinical success rates.

RESULTS

 Using the transarterial approach, there are at least 4 different pathways to access the nidus of a T2EL. CT-guided direct puncture of the aneurysm sac provides an alternative method of high technical success. EVOH with its slow solidification characteristics enables good control to achieve complete filling of the T2EL. During the intervention, however, it remains difficult to meet exactly the embolization endpoint, especially in large T2ELs.

CONCLUSION

 T2EL embolization using EVOH is an effective treatment with low major complication rates when conducted by skilled interventionists with detailed knowledge of diverse complex access routes.

KEY POINTS

  · Many roads lead to Rome to access the nidus of a T2EL including diverse complex transarterial pathways and direct aneurysm sac puncture.. · Ethylene vinyl alcohol co-polymer enables good control for slow filling of the nidus with low risk of major complications.. · Identification of the embolization endpoint remains difficult during the procedure and may result in secondary interventions.. · Successful T2EL embolization requires detailed knowledge of all access routes to the nidus and skilled handling of liquid embolics..

CITATION FORMAT

· Nolte-Ernsting C, Mecklenbeck F, Stehr A. Embolization of Type 2 Endoleaks in the Abdominal Aorta Using Ethylene Vinyl Alcohol Copolymer. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1502-7883.

Predictive Value of Preprocedural Computed Tomography Angiography for the Technical Success of Transarterial Embolization of Type II Endoleaks Arising from the Lumbar Arteries

PURPOSE

To evaluate the ability of preprocedural computed tomography angiography (CTA) to predict the technical success of embolization of type II endoleak arising from a lumbar artery after endovascular aortic repair (EVAR).

MATERIALS AND METHODS

All patients at a single academic institution who underwent angiography with possible embolization for a post-EVAR lumbar-supplied type II endoleak from 2009 to 2018 were retrospectively reviewed. Patients who did not undergo CTA before the procedure were excluded. CTAs were reviewed for the ability to trace the entire course of a feeding vessel from the internal iliac artery (IIA) to the lumbar artery at the site of the endoleak. Procedural imaging was reviewed for technical success, defined as the catheterization and embolization of the aneurysm sac through a lumbar artery.

RESULTS

Fifty-seven angiograms with a type II endoleak and suspected feeding lumbar artery were identified. On CTA acquired before the procedure, the arterial path supplying this lumbar artery could be traced from the IIA to the aneurysm sac in 18 (32%) patients. Embolization was technically successful in 16 of these 18 (89%) procedures compared with 10 of 39 (26%) procedures in which the supplying artery could not be traced using CTA (P < .001).

CONCLUSIONS

A potential catheter path from the IIA through the iliolumbar and lumbar arteries to the aneurysm sac can be traced on preprocedural CTA in the minority of lumbar-supplied type II endoleaks. The ability to trace these inflow vessels may predict technical success during embolization. The low rate of technical success when the feeding vessel could not be traced using CTA suggests that these patients should be considered for percutaneous or transcaval sac puncture.

Computed Tomography Angiography Prediction of Successful Trasnscatheter Embolization for Type II Endoleak of Endovascular Abdominal Aortic Aneurysm Repair

PURPOSE

To evaluate the utility of computed tomography (CT) angiography before transarterial embolization (TAE) in predicting TAE's technical success for type II endoleaks (T2ELs).

MATERIALS AND METHODS

Fifty-eight patients (mean age, 74.4 years; range, 46-89 years) who underwent attempted TAE for T2EL from July 2014 to August 2019 and underwent CT angiography before the procedure were included. Each CT angiography result was assessed for a feeding artery that was traceable over its entire course from either the superior mesenteric artery or the internal iliac artery to the endoleak cavity. TAE was performed using coils and was considered technically successful if embolization of the endoleak cavity and feeding artery was performed. The technical success rates were compared between patients with and without traceable feeding arteries.

RESULTS

A fully traceable feeding artery supplying 75% (44/59) of endoleaks in the cohort was identified. TAE was technically successful in 95% (42/44) of these cases but only in 13% (2/15) of the cases without a fully traceable feeding artery (P < .001). When the inferior mesenteric artery was the feeding artery, it was always fully traceable, and TAE was technically successful in 100% (33/33) of the cases. When a lumbar artery was the feeding artery, it was fully traceable in only 42% (11/26) of the cases. When the lumbar artery was not fully traceable, TAE was technically successful in only 13% (2/15) of the cases.

CONCLUSIONS

The traceability of a feeding artery over its entire course to an endoleak cavity using CT angiography was associated with TAE's technical success. Lumbar feeding arteries were less likely to be fully traceable. TAE's high failure rate when the feeding artery was not fully traceable suggests that translumbar embolization can be considered as an initial approach for theses patients.

Factors Influencing Clinical Success Following Endovascular Treatment of Type II Endoleaks

PURPOSE

To compare long-term outcomes of transarterial (TA) and translumbar (TL) embolization of type II endoleaks (T2E) following EVAR, as well as factors that predict clinical success.

METHODS

129 (mean age, 71.4y; range, 53-95) with T2E referred for embolization from August-2003 to December-2017 were retrospectively reviewed. One-hundred-eighty procedures were performed via TA (n = 139) and TL (n = 41) approaches, with 37 patients undergoing 51 reinterventions. Clinical success was defined as absence of endoleak and/or absence of aneurysm sac enlargement on follow-up imaging. Medical comorbidities, procedural data, embolic agents used, presence of successful sac embolization, and 30-day morbidity and mortality data were collected.

RESULTS

TL approaches had higher technical success (41/41 vs.122/139, p = .014). Clinical success rates were 52% (N = 58/111) and 62% (N = 23/37) for TA and TL procedures respectively (p = .34). Looking at all procedures, sac embolization using n-butyl cyanoacrylate glue had higher clinical success compared to other embolic agents (p = .017-.037). Successful sac access was a strong predictor of success for TA procedures (46/78 vs.12/33, p = .0379). 30-day complication rates were similar between TA (5.8%) and TL (4.9%) approaches. There was 1 death secondary to graft infection following TA embolization.

CONCLUSIONS

Overall clinical success of TA and TL embolization when considering re-interventions is high. n-butyl cyanoacrylate glue had significantly higher success than other embolic agents (p = .017-.037). Successful sac access was associated with success for TA procedures.

Type 2 Endoleak Management

Type 2 endoleaks are the most common endoleak type following endovascular aneurysm repair. The natural history of these endoleaks can vary, with some demonstrating a self-limited or indolent course, while others can contribute to aneurysm sac enlargement and rupture. A variety of embolization techniques, including transarterial catheterization and direct sac puncture techniques, have been developed for the treatment of type 2 endoleaks. In this article, the authors review the indications, techniques, and outcomes of current treatment strategies for type 2 endoleaks.

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.

Type II Endoleaks After EVAR: A Literature Review of Current Concepts

Endoleak is the most frequent complication following endovascular aneurysm repair, which is not present in the surgical counterpart. The most frequent type of endoleak corresponds to type II, and its natural history remains poorly understood. Therefore, their treatment continues to be a topic of debate. The vast majority of the studies found in the literature are of a retrospective nature, and there are no prospective studies comparing intervention versus a conservative approach. Future studies should aim to compare not only different approaches to resolve type II endoleak but also when should be the right time to treat them, with the primary purpose of avoiding sac rupture. The objective of this review is to provide the reader with a literature overview about type II endoleaks to help in the decision-making process on this topic.

Early and Late Outcomes of Ultrasound-Guided Direct Transabdominal Embolization of Isolated Type 2 Endoleaks after Endovascular Aortic Repair

BACKGROUND

The aim of this study is to report the early and late outcomes of ultrasound-guided direct transabdominal embolization (UGDTE) of isolated type 2 endoleak (T2EL) after endovascular aneurysm repair (EVAR).

METHODS

Forty-two consecutive T2EL patients were treated between February 2000 and September 2017 by UGDTE after previous EVAR. During the study period, UGDTE was the firs-line technique implemented for treatment of T2EL. All procedures were carried out using the same predefined technique. Aneurysm sac size change from the index treatment, freedom from recurrent endoleak after treatment, demographics, risk factors, and procedural factors were analyzed with univariate analysis.

RESULTS

During the study interval, 612 patients underwent standard EVAR for abdominal aortic aneurysm treatment and 111 (18.2%) developed an isolated T2EL. Of these, 42 (6.8%) consecutive patients were deemed suitable and treated with UDGT. Median imaging follow-up duration was 18.7 months. Median fluoroscopic and procedure times were 7 and 58 minutes, respectively. The rate of immediate technical success was 100%. Ten patients (23.8%) underwent reintervention for recurrent T2EL. Freedom from reintervention for T2EL at 1, 2, and 4 years was 81%, 78%, and 71%. No aneurysm-related mortality occurred during the follow-up period.

CONCLUSIONS

The use of UGDTE for treatment of isolated T2EL after EVAR is a safe and feasible technique when performed by experienced operators, resulting in high technical success and low complication rates in selected patients. Although being effective in obtaining T2EL exclusion, up to one-third of the patients may require repeat intervention during long-term follow-up. Therefore, lifelong surveillance after the procedure is recommended.

Recent Update of Endovascular Type 2 Endoleak Management

EVAR has been used clinically for almost three decades, and it has been widely applied in clinical practice and has been applied to difficult cases as devices and techniques have evolved. Although the major advantage of EVAR is its lower perioperative mortality, compared with open surgery, late-onset complications such as endoleaks have become major issues, requiring lifelong follow-up after EVAR. The clinical guidelines have been updated, and many systematic reviews/meta-analyses and multi-center registries have been published; surgeons must keep up-to-date regarding these changes. In this review, the author reviews evidence on the recent update of the type 2 endoleak management.