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Endovascular aneurysm aneurysm sac sealing with the Endologix Nellix® system. A and B) Endovascular deployment of bilateral aorto-iliac stent grafts that extent from the infrarenal aortic neck to the distal bilateral common iliac arteries. A type II endoleak is visualized via retrograde distal aortic lumbar arteries (A). C and D) Filling of endograft endobag with a biopolymer solution obliterates the aneurysm sac from potential type II endoleaks.
Source publication
Type II endoleaks occur commonly following endovascular aneurysm repair (EVAR). Although they remain enigmatic, multiples studies have evaluated preoperative risk factors and strategies for prevention of type II endoleaks. Prophylactic treatment of type II endoleaks can include embolization of accessory arteries, as well as complete aneurysmal sac...
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Methods:
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Purpose:
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Methods:
The global, multicenter RATIONALE registry ( ClinicalTrials.gov; identifier NCT03449875) prospectively enrolled 202 patients (mean age 73.0±7.8 years; 187 men) with abdominal aortic aneurysms (AAA) suitable for endovascular aneurysm repair (EVAR) using the Tre...
Citations
... Currently, EVAR is appropriate for patients with aneurysms larger than 5.5 cm. Patients must be followed up with at 1, 6, and 12 months post-EVAR, and annually afterwards, to detect post-EVAR complications [6,21,67]. Currently, imaging modalities such as CTA, MRA or DUX are used in clinical practice to screen the patients after EVAR procedure, which are cost representative for the health-care system [18,19,68,69]. These techniques have different advantages and disadvantages (see Table 3) for EVAR surveillance [63,70]. ...
Over the past two decades, there has been extensive research into surveillance methods for the post-endovascular repair of abdominal aortic aneurysms, highlighting the importance of these technologies in supplementing or even replacing conventional image-screening modalities. This review aims to provide an overview of the current status of alternative surveillance solutions for endovascular aneurysm repair, while also identifying potential aneurysm features that could be used to develop novel monitoring technologies. It offers a comprehensive review of these recent clinical advances, comparing new and standard clinical practices. After introducing the clinical understanding of abdominal aortic aneurysms and exploring current treatment procedures, the paper discusses the current surveillance methods for endovascular repair, contrasting them with recent pressure-sensing technologies. The literature on three commercial pressure-sensing devices for post-endovascular repair surveillance is analyzed. Various pre-clinical and clinical studies assessing the safety and efficacy of these devices are reviewed, providing a comparative summary of their outcomes. The review of the results from pre-clinical and clinical studies suggests a consistent trend of decreased blood pressure in the excluded aneurysm sac post-repair. However, despite successful pressure readings from the aneurysm sac, no strong link has been established to translate these measurements into the presence or absence of endoleaks. Furthermore, the results do not allow for a conclusive determination of ongoing aneurysm sac growth. Consequently, a strong clinical need persists for monitoring endoleaks and aneurysm growth following endovascular repair.
... Although type II endoleaks do not cause adverse events in the short term, persistent type II endoleaks may result in sac enlargement, leading to aneurysm rupture. According to previous studies, risk factors of persistent type II endoleaks include advanced age, aneurysm diameter and patent branches from an aneurysm [3][4][5]. In addition, Muller-Wille et al. reported that 'f low-through' type II endoleaks that have feeding and drainage arteries are a high-risk factor for aneurysm enlargement [6]. ...
Identification and control of responsible feeding arteries are crucial in treating type II endoleaks after endovascular aortic repair (EVAR). A 78-year-old female patient required management of a type II endoleak 8 years after EVAR. A persistent endoleak from the inferior mesenteric artery (IMA) enlarged the size of an aneurysm sac. Sac angiography from the IMA revealed a flow-through endoleak from the IMA to an aberrant renal artery (ARA). After coil embolization of the ARA through the sac together with the IMA, the sac shrank. Control of flow-through vessels may be essential for managing post-EVAR enlargement due to type II endoleaks.
... 7 Type II endoleaks (TIIELs) are the most frequent type of them, with some studies reporting rates as high as 29%, and others as low as 6.3% of the patients treated by EVAR. 8 Type II endoleaks are often benign but have been associated with a higher incidence of aneurysm growth and more secondary endovascular procedures. 9 Rupture due to TIIEL is only rarely reported, accounting for less than 1% of all TIIELs. ...
... 13 Advancements in EVAR, and its wide application, have demonstrated compelling trends in decreasing AAA-related morbidity and mortality. 8 However, reintervention rates due to complications following EVAR are persistent, with endoleak being a significant set of them. 13 Type II endoleak represents retrograde bleeding into the aneurysm sac, most commonly from lumbar arteries, the inferior mesenteric artery, or other collateral vessels. 1 They resolve spontaneously within 6 to 12 months in about 80% of the cases, but some will later present with a type I endoleak, resulting in a high secondary intervention rate and significant risk of aneurysm-related complications. ...
Purpose
Endovascular abdominal aortic aneurysm repair (EVAR) is progressively being applied in the elderly population. Type II endoleaks are common and mostly benign, but they are related to more aneurysm sac expansion after EVAR. They may lead to rupture in <1% of cases. We present a case of a centenarian with a post-EVAR rupture, related to type II endoleak, and discuss the use of EVAR on the management of this type of endoleak in an extremely old patient.
Case Presentation
A 102-year-old man with a history of EVAR 12 years earlier, presented to the emergency department with a drop of consciousness. A computed tomography revealed a ruptured abdominal aortic aneurysm. Angiography showed a type II endoleak related to patent lumbar arteries deriving from collateral branches of the right internal iliac artery. Embolization was not successful and subsequently the ostium of the iliolumbar artery was overstented, obliterating the feeding branch. The postoperative course was complicated by a deterioration of chronic obstructive pulmonary disease and patient was discharged home on the seventh postprocedural day; nonetheless, he died on postoperative day sixteenth due to respiratory complications.
Conclusion
Complications following EVAR are a real threat and emphasize the need for follow-up. The current case report shows that age per se should not be a contraindication for EVAR nor for follow-up. Also, late ruptures due to type II endoleaks could be treated in the very elderly population although larger series are required for robust conclusions.
... In these cases, the sac is exposed to a low-pressure flow that may lead to sac enlargement over time. The evolution can be slow and the endoleak can either be managed conservatively [18,19] or lead to sac expansion over 5 mm in a year in which case treatment will be deemed necessary [20][21][22][23]. According to the type of endoleak, different approaches may be followed [24]. ...
Abstract The presence of endoleaks remains one of the main drawbacks of endovascular repair of abdominal aortic aneurysms leading to the increase of the size of the aneurysmal sac and in most of the cases to repeated interventions. A variety of devices and percutaneous techniques have been developed so far to prevent and treat this phenomenon, including sealing of the aneurysmal sac, endovascular embolisation, and direct sac puncture. The aim of this review is to analyse the indications, the effectiveness, and the future perspectives for the prevention and treatment of endoleaks after endovascular repair of abdominal aortic aneurysms.
... Branching vessels from the aneurysm, including inferior mesenteric artery, lumbar arteries, and median sacral artery, are considered as a major collateral pathway responsible for type II endoleak after EVAR. The number of patent lumbar arteries, patent inferior mesenteric artery, and cross-sectional area of the aorta around the ostium of the inferior mesenteric artery are suggested as predictors for type II endoleak after EVAR (30)(31)(32). However, there are controversies for prophylactic embolization of branching vessels to prevent type II endoleak. ...
Abdominal aortic aneurysm (AAA) can be defined as an abnormal, progressive dilatation of the abdominal aorta, carrying a substantial risk for fatal aneurysmal rupture. Endovascular aneurysmal repair (EVAR) for AAA is a minimally invasive endovascular procedure that involves the placement of a bifurcated or tubular stent-graft over the AAA to exclude the aneurysm from arterial circulation. In contrast to open surgical repair, EVAR only requires a stab incision, shorter procedure time, and early recovery. Although EVAR seems to be an attractive solution with many advantages for AAA repair, there are detailed requirements and many important aspects should be understood before the procedure. In this comprehensive review, fundamental information regarding AAA and EVAR is presented.
... The final goal is to definitively stop the blood flow in these collateral arteries with appropriate embolic agents which should cause thrombosis and cessation of the EL [29]. ...
Endovascular aneurysm repair (EVAR) is associated with decreased periprocedural mortality, complications, and length of hospital stay compared to open repair. Endoleaks can occur in 20–25% of patients after EVAR, with type II endoleaks being the most common. They commonly occur from retrograde collateral blood flow into the aneurysm sac, typically from a lumbar artery or the inferior mesenteric artery (IMA). Type II endoleaks are only treated if there is evidence of aneurysm growth (generally >5 mm). There are multiple approaches to the management of these endoleaks, including transarterial, translumbar, transcaval, and surgical approaches. This chapter will look at the endovascular treatments, analyzing techniques, results, and modern tools available.
... Endovascular aortic aneurysm repair (EVAR) is the most common method for repairing abdominal aortic aneurysms (AAA). Type II endoleaks following EVAR is common and can occur in up to 34% of repairs [1]. Although Type II endoleaks are commonly regarded as benign, in unique circumstances they can lead to continued aneurysm growth, and can rarely lead to sac rupture [2]. ...
... Here we report a unique presentation of a rAAA with a large Type II endoleak and thrombus-seal Type Ia endoleak. Although large chronic Type II endoleaks can lead to aneurysm sac expansion and rupture, this is rare and is estimated to occur in 4.5% of patients with endoleaks [1,2]. Alternatively, progressive aneurysm degeneration of the juxta-renal aorta following EVAR can lead to inadequate proximal aortic neck Type Ia endoleak [3]. ...
... There are multiple treatment strategies for chronic Type II endoleaks [1,6]. Patients who have an expanding AAA with a chronic Type II endoleak are acceptable candidates for attempted embolization [1,7]. ...
Ruptured abdominal aortic aneurysm (rAAA) with an associated Type II endoleak is rare. Emergent surgical repair is often necessary and may be associated with high morbidity and mortality. We report an alternative unique trans-luminal repair strategy in an 84-year-old male who presented with a rAAA with prior EVAR, and Type Ia and Type II endoleaks. The operative strategy consisted of proximal endograft extension into the para-renal aorta, followed by staged sac embolization using glue. Postoperatively, the patient recovered well from the repair, and follow-up imaging demonstrated a stable repair.
Type 2 endoleaks are a potential complication of endovascular aortic repair for abdominal aortic aneurysms. They are caused by vessels that have been excluded from the aorta lumen, but may still fill the aneurysm sac due to collateral filling. Type 2 endoleaks may lead to increased morbidity and need for additional procedures. Being able to identify patients at risk for Type 2 endoleaks and prevent them is important for any physician who is performing endovascular aortic repair.
