Preoperative Embolization of Collateral Side Branches: A Valid Means to Reduce Type II Endoleaks After Endovascular AAA Repair

Abstract

To report the results of preprocedural embolization of collateral branches arising from abdominal aortic aneurysms (AAA) scheduled for endovascular repair.
Twenty-three consecutive AAA patients (all men; mean age 73 years, range 56-82) had coil embolization of patent lumbar and inferior mesenteric arteries (IMA) in a staged procedure prior to endovascular repair. Embolization with microcoils was attempted in 37 of the 52 identified lumbar arteries and 14 of 15 inferior mesenteric arteries. Follow-up included biplanar abdominal radiography, spiral computed tomography, and duplex ultrasonography at 1, 30, 90, and 180 days after the stent-graft procedure and at 6-month intervals thereafter.
Successful embolization was obtained in 24 (65%) of lumbar arteries, while all 14 (100%) IMAs were occluded with coils. No complication was associated with embolotherapy. Over a mean 17-month follow-up of 22 patients (1 intraoperative death), there was only 1 (4.5%) type II endoleak from a patent lumbar artery, with no sac expansion after 2 years. There were 4 (18%) type I and 1 (4.5%) type III endoleaks.
The embolization of side branches arising from an infrarenal aortic aneurysm before endovascular repair is feasible, with a high success rate; this maneuver may play a relevant role in reducing the rate of type II endoleak, improving long-term outcome.

Full text

J ENDOVASC THER
2003;10:227–232
227
Q2003 by the I
NTERNATIONAL
S
OCIETY OF
E
NDOVASCULAR
S
PECIALISTS
Available at www.jevt.org
l
CLINICAL INVESTIGATION
l
Preoperative Embolization of Collateral Side
Branches: A Valid Means to Reduce Type II
Endoleaks After Endovascular AAA Repair
Robert Bonvini, MD
1
; Mario Alerci, MD
2
; Francesco Antonucci, MD
2
;
Paolo Tutta, MD
1
; Rolf Wyttenbach, MD
4
; Marcel Bogen, MD
3
;
Angelo Pelloni, MD
3
; Ludwig von Segesser, MD
5
; and Augusto Gallino, MD
1
Departments of
1
Vascular Medicine,
2
Interventional Radiology,
3
Surgery, and
4
Radiology, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland; and
5
Division of Cardiovascular Surgery, CHUV, Lausanne, Switzerland
l
l
Purpose:
To report the results of preprocedural embolization of collateral branches arising
from abdominal aortic aneurysms (AAA) scheduled for endovascular repair.
Methods:
Twenty-three consecutive AAA patients (all men; mean age 73 years, range 56–
82) had coil embolization of patent lumbar and inferior mesenteric arteries (IMA) in a
staged procedure prior to endovascular repair. Embolization with microcoils was attempted
in 37 of the 52 identified lumbar arteries and 14 of 15 inferior mesenteric arteries. Follow-
up included biplanar abdominal radiography, spiral computed tomography, and duplex
ultrasonography at 1, 30, 90, and 180 days after the stent-graft procedure and at 6-month
intervals thereafter.
Results:
Successful embolization was obtained in 24 (65%) of lumbar arteries, while all 14
(100%) IMAs were occluded with coils. No complication was associated with embolother-
apy. Over a mean 17-month follow-up of 22 patients (1 intraoperative death), there was
only 1 (4.5%) type II endoleak from a patent lumbar artery, with no sac expansion after 2
years. There were 4 (18%) type I and 1 (4.5%) type III endoleaks.
Conclusions:
The embolization of side branches arising from an infrarenal aortic aneurysm
before endovascular repair is feasible, with a high success rate; this maneuver may play
a relevant role in reducing the rate of type II endoleak, improving long-term outcome.
J Endovasc Ther 2003;10:227–232
Key words:
abdominal aortic aneurysm, endovascular repair, stent-graft, complication, en-
doleak, lumbar artery, inferior mesenteric artery, coil embolization
l
l
Drs. Bonvini and Alerci contributed equally to the paper.
Address for correspondence and reprints: Prof. Dr. Augusto Gallino, Department of Cardiovascular
Medicine, Ospedale Regionale Bellinzona e Valli, CH-6500 Bellinzona, Switzerland. Fax: 41-91-811-91-
69; E-mail:
agallino@bluewin.ch
The most frequent mid and long-term com-
plications observed after endovascular repair
of abdominal aortic aneurysms (AAA) are en-
doleaks,
1–5
which occur in up to 45%
3
of cas-
es. Patients with aortic endografts require
regular surveillance with computed tomog-
raphy (CT), duplex ultrasonography, or mag-
netic resonance imaging (MRI).
6–8
When en-
doleaks are found, additional endovascular
interventions or even conversion to open re-
pair may be needed,
4,9
which drives up the
overall costs of AAA treatment.
White and colleagues
10–12
in Australia first
categorized endoleaks as types I through IV,

228 PRE-ENDOGRAFT SIDE BRANCH EMBOLIZATION
Bonvini et al.
J ENDOVASC THER
2003;10:227–232
but the focus of our report is on type II, which
refers to retrograde perfusion through collat-
eral branches. Although type II leaks may re-
solve spontaneously,
13
they may also lead to
further expansion of the aneurysm sac, per-
petuating the risk of rupture.
3,6,14–16
Type II en-
doleaks can transmit pressure to the aneu-
rysm sac,
17,18
and several authors have noted
that even a minor type II endoleak inhibits sac
shrinkage.
8,14,19,20
On the other hand, we were
able to find only 2 patients with type II en-
doleak who died after sac rupture.
21–24
Development of a type II endoleak after en-
dovascular aneurysm repair (EVAR) seems to
be correlated with the number of collateral
branches present before the operation,
13,15,25
although this explanation is not unanimously
accepted.
7,26,27
We conducted a study to ex-
amine the hypothesis that meticulous preop-
erative microcoil embolization of patent col-
lateral branches in endograft candidates
could significantly reduce the postoperative
incidence of type II endoleaks.
METHODS
Under a protocol approved by our ethical
committee, we obtained informed consent to
embolize patent side branches from 23 con-
secutive AAA patients (all men; mean age 73
years, range 56–82) undergoing EVAR be-
tween March 1999 and December 2001. The
patients’ cardiovascular risk factors and co-
morbidities included hypertension (13, 56%),
hyperlipidemia (9, 39%), diabetes (4, 17%),
coronary artery disease (9, 39%), peripheral
arterial disease (8, 35%), mild renal failure (11,
48%), and mild to severe pulmonary disease
(5, 22%). The aneurysms were categorized ac-
cording to the EUROSTAR classification
28
as
type A (4, 17%), type B (18, 78%), and type D
(1, 4%).
Preoperative spiral CT was performed with
a Tomoscan Advantage scanner (Phillips
Medical Systems, Best, The Netherlands) at 5-
mm slice thickness, 10-mm table speed, with
5-mm reconstruction intervals during bolus
injection of 150 mL of Optiray 300 (Guerbet,
Paris, France) at a 3-mL/s flow rate and scan
delay of 30 seconds. Postprocessing was per-
formed with an Easy Vision satellite worksta-
tion (Philips Medical Systems) to obtain mul-
tiplanar reconstructions (MPR) and maximum
intensity projections (MIP) of the entire aorta.
Digital subtraction angiography was per-
formed with a standard angiography unit (In-
tegris V 3000; Philips Medical Systems). A 5-
F calibrated pigtail catheter (PBM Medicals,
Stenloese, Denmark) was positioned in the
abdominal aorta, and examinations of the
aorta and pelvic arteries were made in an-
teroposterior, left and right anterior oblique,
and lateral views with multiple 20-mL injec-
tions of Hexabrix 300 (Guerbet) at a flow rate
of 20 mL/s. The total amount of contrast me-
dium varied from 120 to 150 mL.
According to the study plan, all patent in-
ferior mesenteric arteries (IMA) were to un-
dergo coil embolization in a staged procedure
prior to EVAR. The threshold for treating pat-
ent lumbar arteries (LA) was an arteriograph-
ically-measured diameter .2.5 mm or .2.0
mm without ostium stenosis; LAs with a di-
ameter ,2.0 mm were not treated, nor were
LAs arising from the proximal or distal neck
in the event they would be covered by the
prosthesis.
The preoperative examinations identified
52 patent LAs arising from the aneurysm sac
in 16 patients, but only 37 met the diameter
criterion. Fifteen patent IMAs were found in
15 patients. One patent IMA arose distal to the
aneurysm sac and therefore was not embo-
lized because it would be covered by the
prosthesis. In 7 cases, there was no patent LA,
and 8 patients had an occluded IMA.
Embolization was performed in a separate
session ;15 days before endovascular AAA
repair. The coaxial catheterization technique
employed a microcatheter (Transit, Cordis,
Johnson and Johnson AG, Spreitenbach,
Switzerland; or Turbo Tracker, Boston Scien-
tific, Solothurn, Switzerland) and a 4 or 5-F
diagnostic catheter as the guiding catheter
(Sim1, Sim2, C1, C2, C3; Cordis or Cook, Sur-
see, Switzerland) for direct injection of micro-
coils (Vortex, Boston Scientific; Trufill, Cordis).
The time for the procedure varied from 0.75
to 2.5 hours depending on the number of the
vessels to be embolized (Figure).
For subsequent aneurysm exclusion, 19 bi-
furcated stent-grafts (14 Talent [Medtronic
World Medical, Sunrise, FL, USA] and 5 Ex-
cluder [W.L. Gore and Associates, Flagstaff,

J ENDOVASC THER
2003;10:227–232
PRE-ENDOGRAFT SIDE BRANCH EMBOLIZATION
Bonvini et al.
229
AZ, USA]) were used in addition to 2 aorto-
monoiliac prostheses (Talent) with crossover
bypass and 2 tube endografts (Talent). Biplan-
ar abdominal radiograms, duplex ultrasound
scans, and abdominal spiral CT scans were
performed at 1, 30, 90, and 180 days after the
procedure and at 6-month intervals thereafter.
The same operator (P.T.) always performed
the duplex studies using a Sequoia 256 scan-
ner (Acuson, Mountain View, CA, USA) to
identify endoleak and measure the diameters
of the aneurysm sac. The CT scan was per-
formed at 5-mm thickness, 10-mm table
speed, pitch 1:2, and 3-mm reconstruction in-
tervals using a triphasic technique: before
and then during contrast injection (150 mL of
Hexabrix 300 at a 3-mL/s flow rate and a scan
delay of 30 seconds) and 2 minutes after in-
jection. If sac shrinkage was documented af-
ter the first year, then only duplex imaging
and abdominal radiography were done at the
6-month examinations.
RESULTS
In embolization sessions performed 2 to 21
days before stent-graft implantation, 24 (65%)
of 37 LAs identified for embolized were suc-
cessfully occluded. The 13 failures were due
to an inability to catheterize the vessel. All 14
(100%) patent IMAs were successfully embo-
lized. This produced complete collateral
branch embolization in 9 (39%) of 23 patients;
another 9 (39%) had only partial branch oc-
clusion owing to procedural failure in 5 (22%)
or to small LAs in 4 (17%). The other 5 (22%)
patients presented with spontaneous occlu-
sion of the LA and IMA. No complications oc-
curred during or after the embolization pro-
cedures.
There was 1 (4.3%) death related to the
EVAR procedure; the patient sustained an iliac
artery rupture and died of multiorgan failure
subsequent to hemorrhage shock. The re-
maining 22 patients were followed for a mean
17 months (range 3–36). There were 4 (18%)
type I endoleaks, 3 detected immediately after
EVAR and 1 diagnosed a year later. According
to the guidelines proposed by Go¨ rich et al.,
3
2 of these type I endoleaks originated from
the proximal anastomosis (type IA, one early
and one late), 1 at the distal anastomosis
(type IB, early), and the fourth from the iliac
artery occluder (type IC, early). At the 3-
month CT scan, 2 (early IA and IC) had sealed
spontaneously. The other 2 (late IA, early IB)
were still present at 3 months and so were
treated with transcatheter embolization. How-
ever, despite embolization, the aneurysm with
the type IB endoleak showed continuous ex-
pansion, and a second bifurcated stent-graft
was implanted. A type III endoleak was found
in this patient 1 year later.
Only 1 (4.5%) type II endoleak was seen on
the 1-day postprocedural CT scan; the mini-
mal posterior contrast enhancement indicated
a lumbar artery etiology. This patient had only
partial preprocedural branch embolization
(IMA successful, but only 3 of 6 LAs embo-
lized). This type II endoleak was treated con-
servatively since there was no evidence of sac
expansion during the 2-year follow-up.
In 8 (36%) AAAs, the sac reduced in diam-
eter from an average of 64 361 mm preop-
eratively to 51 353 mm postoperatively; the
remaining 13 (59%) AAAs demonstrated no
significant change in diameter. Among the 8
patients with sac shrinkage, 4 had complete
collateral occlusion (3 embolized, 1 with spon-
taneous occlusion). Three had only partial
embolization due to technical failure, and 1
had no embolization because of a small LA.
The only instance of sac expansion was the
patient mentioned above who underwent a
secondary stent-graft procedure after embo-
lization failed to resolve a type IB endoleak.
DISCUSSION
The incidence of type II endoleaks persisting
beyond 6 months is reported in the range of
3.5% to 28%,
2,3,6,7,15,29
and it may be respon-
sible for increased EVAR-related morbidity
with potential risk of rupture.
3,6,14,15,16
This po-
tential risk, in association with sac expansion,
is equivalent to procedural failure and is of
major concern.
8,19,23,24,30–33
Some authors re-
ported sac expansion or rupture in the face of
a type II endoleak.
23,24,31
Others advised an
aggressive attitude be assumed in cases of
sac expansion even without evidence of en-
doleak
32
or stated that sac shrinkage is the
only parameter that indicates successful
EVAR.
8
For this reason, many authors have

230 PRE-ENDOGRAFT SIDE BRANCH EMBOLIZATION
Bonvini et al.
J ENDOVASC THER
2003;10:227–232
Figure
l
(A) A preoperative right anterior oblique abdominal angiogram indicates patent lum-
bar (arrowhead) and inferior mesenteric (arrow) arteries arising from the aneurysm sac in a
patient with a type B aortic aneurysm. (B) The same patient after successful coil embolization.
used a variety of percutaneous procedures to
treat these postoperative endoleaks, includ-
ing sac embolization with coils, glue, or
thrombin, or retrograde catheterization to oc-
clude the IMA or LA.
The best treatment modality, however, is
still a question of debate. Furthermore, all
these techniques are often time-consuming
and are not uniformly successful.
9,13,15,33–35
Recently, the translumbar approach has been
proposed by some authors as the first choice
treatment strategy for type II endoleaks.
34
Other authors suggest that LA occlusion by
injection of gelatin sponge in the aneurysm
sac during the EVAR may reduce the devel-
opment of side branch–related endoleaks.
36
However, Gould et al.
7
suggested that pre-
operative embolization of collateral branches
had no beneficial effect on type II endoleaks.
Their incidence of early type II endoleaks in
patients with or without preoperative embo-
lization was 20% and 23%, respectively, with
similar results at 6 months (10% incidence of
type II for both groups). On the other hand,
Parry et al.
8
performed preoperative emboli-
zation of the sac feeders (IMA and LA). They
found no type II endoleak among 13 patients
who had occluded side branches at baseline
or 14 patients who underwent successful IMA
or LA embolization. Conversely, 8 of 13 pa-
tients with patent LAs developed a type II
lumbar endoleak.
To avoid or at least to reduce the occur-
rence of endoleaks, we prospectively per-
formed meticulous preoperative microcoil
embolization of patent collateral branches in
a consecutive series of EVAR candidates. Ev-
ery patent IMA arising from the aneurysm sac
was embolized, whereas the decision on
which LAs required embolization was at the
discretion of the interventionist. Arbitrary cri-
teria (.25-mm diameter or .20 mm if no os-
tial stenosis existed) were established be-
cause large LAs are easier to catheterize and
embolize; microcoil embolization was at-
tempted even in the presence of a thrombotic
corona in the aneurysm sac.
This approach proved feasible in our rela-
tively small prospective series, achieving a
high success rate. In follow-up, we observed
only a single (4.5%) type II endoleak, which
we believe supports the hypothesis that pre-
operative embolization of collateral branches
can reduce the number of type II endo-

J ENDOVASC THER
2003;10:227–232
PRE-ENDOGRAFT SIDE BRANCH EMBOLIZATION
Bonvini et al.
231
leaks.
13,15,25
To our knowledge, only Hovsepi-
an et al.
29
have reported a lower incidence of
this complication (3.5%).
Type I endoleaks were found more fre-
quently than type II in our series, but half of
these sealed spontaneously within a 3-month
period, which may mean that type I endoleak
is also associated with patent collateral
branches present preoperatively, as recently
reported by Fan et al.
15
Major limitations of our study are the rela-
tively small patient population and a midterm
follow-up averaging 17 months. This short
observation period could explain why only a
relatively small percentage of patients had
significant sac shrinkage. Moreover, endo-
leaks may occur even beyond 1 year after
EVAR, especially in cases where preoperative
side branch embolization has not been per-
formed.
7
Another shortcoming to the study
was the absence of a control group without
preoperative embolization.
Despite these limitations, the 4.5% inci-
dence of type II endoleak is very low com-
pared to previous reports
1–3,6,7,15
and may
support our preventive strategy if corroborat-
ed by further studies with a larger number of
patients. We believe that preoperative side
branch embolization is safe and easier to per-
form preoperatively than after the EVAR pro-
cedure. This maneuver may contribute to a
reduction in the rate of type II endoleak and
improve the long-term outcome after EVAR.
REFERENCES
1. Ohki T, Veith FJ, Shaw P, et al. Increasing inci-
dence of midterm and long-term complications
after endovascular graft repair of abdominal
aortic aneurysms: a note of caution based on
a 9-year experience.
Ann Surg.
2001;234:323–
335.
2. Becker GJ, Kovacs M, Mathison MN, et al. Risk
stratification and outcomes of transluminal en-
dografting for abdominal aortic aneurysm: 7-
year experience and long-term follow-up.
J
Vasc Interv Radiol.
2001;12:1033–1046.
3. Go¨ rich J, Rilinger N, Sokiranski R, et al. Leak-
ages after endovascular repair of aortic aneu-
rysms: classification based on findings at CT,
angiography, and radiography.
Radiology.
1999;213:767–772.
4. Go¨ rich J, Rilinger N, So¨ ldner J, et al. Endovas-
cular repair of aortic aneurysms: treatment of
complications.
J Endovasc Surg.
1999;6:136–
146.
5. Blum U, Voshage G, Lammer J, et al. Endolu-
minal stent-grafts for infrarenal abdominal aor-
tic aneurysms.
N Engl J Med.
1997;336:13–20.
6. Haulon S, Willoteaux S, Koussa M, et al. Di-
agnosis and treatment of type II endoleak after
stent placement for exclusion of an abdominal
aortic aneurysm.
Ann Vasc Surg.
2001;15:148–
154.
7. Gould DA, McWilliams RG, Edwards RD, et al.
Aortic side branch embolization before endo-
vascular aneurysm repair: incidence of type II
endoleak.
J Vasc Interv Radiol.
2001;12:337–
341.
8. Parry DJ, Kessel DO, Robertson I, et al. Type II
endoleaks: Predictable, preventable, and some-
times treatable?
J Vasc Surg.
2002;36:105–110.
9. Amesur NB, Zajko AB, Orons, PD, et al. Embo-
lotherapy of persistent endoleaks after endovas-
cular repair of abdominal aortic aneurysm with
the Ancure Endovascular Technologies endo-
graft system.
J Vasc Interv Radiol.
1999;10:1175–
1182.
10. White GH, Yu W, May J, et al. Endoleak as a
complication of endoluminal grafting of ab-
dominal aortic aneurysms: classification, inci-
dence, diagnosis, and management.
J Endo-
vasc Surg.
1997;4:152–168.
11. White GH, May J, Waugh RC, et al. Type III and
type IV endoleak: toward a complete definition
of blood flow in the sac after endoluminal AAA
repair.
J Endovasc Surg.
1998;5:305–309.
12. White GH, May J, Waugh RC, et al. Type I and
type II endoleaks: a more useful classification
for reporting results of endoluminal AAA repair
[letter].
J Endovasc Surg.
1998;5:189–191.
13. Go¨ rich J, Rilinger N, Sokiranski R, et al. Endo-
leaks after endovascular repair of aortic aneu-
rysm: are they predictable? Initial results.
Ra-
diology.
2001;218:477–480.
14. Malina M, Ivancev K, Chuter TAM, et al. Chang-
ing aneurysmal morphology after endovascu-
lar grafting: relation to leakage or persistent
perfusion.
J Endovasc Surg.
1997;4:23–30.
15. Fan CM, Rafferty EA, Geller SC, et al. Endovas-
cular stent-graft in abdominal aortic aneu-
rysms: the relationship between patent vessels
that arise from the aneurysmal sac and early
endoleak.
Radiology.
2001;218:176–182.
16. Cartes-Zumelzu F, Lammer J, Hoelzenbein T, et
al. Endovascular placement of a nitinol e-PTFE
stent-graft for abdominal aortic aneurysms: ini-
tial and midterm results.
J Vasc Interv Radiol.
2002:13:465–473.

232 PRE-ENDOGRAFT SIDE BRANCH EMBOLIZATION
Bonvini et al.
J ENDOVASC THER
2003;10:227–232
17. Baum RA, Carpenter JP, Cope C, et al. Aneu-
rysm sac pressure measurements after endo-
vascular repair of abdominal aortic aneurysms.
J Vasc Surg.
2001;33:32–41.
18. Schurink GWH, Aarts NJM, Wilde J, et al. En-
doleakage after stent-graft treatment of ab-
dominal aneurysm: implications on pressure
and imaging—an in vitro study.
J Vasc Surg.
1998;28:234–241.
19. Liewald F, Ermis C, Gorich J, et al. Influence of
treatment of type II leaks on the aneurysm sur-
face area.
Eur J Vasc Endovasc Surg.
2001;21:
339–343.
20. Arko FR, Rubin GD, Johnson BL, et al. Type-II
endoleaks following endovascular AAA repair:
preoperative predictors and long-term effects.
J Endovasc Ther.
2001;8:503–510.
21. Zarins CK, White RA, Fogarty TJ. Aneurysm
rupture after endovascular repair using the
AneuRx stent graft.
J Vasc Surg.
2000;31:960–
970.
22. Politz JK, Newman VS, Stewart MT. Late ab-
dominal aortic aneurysm rupture after AneuRx
repair: a report of three cases.
J Vasc Surg.
2000;31:599–606.
23. White RA, Donayre C, Walot I, et al. Abdominal
aortic aneurysm rupture following endolumin-
al graft deployment: report of a predictable
event.
J Endovasc Ther.
2000;7:257–262.
24. Hinchliffe RJ, Singh-Ranger R, Davidson IR, et
al. Rupture of an abdominal aortic aneurysm
secondary to type II endoleak.
Eur J Vasc En-
dovasc Surg.
2001;22:563–565.
25. Velazquez OC, Baum RA, Carpenter JP, et al.
Relationship between preoperative patency of
the inferior mesenteric artery and subsequent
occurrence of type II endoleak in patients un-
dergoing endovascular repair of abdominal
aortic aneurysms.
J Vasc Surg.
2000;32:777–
788.
26. Petrik PV, Moore WS. Endoleaks following en-
dovascular repair of abdominal aortic aneu-
rysm: the predictive value of preoperative an-
atomic factors—a review of 100 cases.
J Vasc
Surg.
2001;33:739–744.
27. Broeders IAMJ, Blankensteijn JD, Eikelboom
BC. The role of infrarenal aortic side branches
in the pathogenesis of endoleaks after endo-
vascular aneurysm repair.
Eur J Vasc Endovasc
Surg.
1998;16:419–426.
28. Harris PL, Buth J, Mialhe C, et al. The need for
clinical trials of endovascular stent-graft tech-
niques for abdominal aortic aneurysm repair:
the EUROSTAR project.
J Endovasc Surg.
1997;
4:72–77.
29. Hovsepian DM, Hein AN, Pilgram TK, et al. En-
dovascular abdominal aortic aneurysm repair
in 144 patients: correlation of aneurysm size,
proximal aortic neck length, and procedure-re-
lated complications.
J Vasc Interv Radiol.
2001;
12:1373–1382.
30. Torsello GB, Klenk E, Kasprzak B, et al. Rupture
of abdominal aortic aneurysm previously treat-
ed by endovascular stent-graft.
J Vasc Surg.
1998;28:184–187.
31. Schurink GWH, Aarts NJM, van Baalen JM, et
al. Late endoleak after endovascular therapy
for abdominal aortic aneurysm.
Eur J Vasc En-
dovasc Surg.
1999;17:448–450.
32. Veith FJ, Baum RA, Ohki T, et al. Nature and
significance of endoleaks and endotension:
Summary of opinions expressed at an inter-
national conference.
J Vasc Surg.
2002:35:
1029–1038.
33. Ivancev K, Chuter TAM, Lindh M, et al. Options
for treatment of persistent aneurysm perfusion
after endovascular repair.
World J Surg.
1996;
20:673–678.
34. Baum RA, Carpenter JP, Golden MA, et al.
Treatment of type 2 endoleaks after endovas-
cular repair of abdominal aortic aneurysms:
comparison of transarterial and translumbar
techniques.
J Vasc Surg.
2002;35:23–29.
35. Chuter TAM, Faruqi RM, Sawhney R, et al. En-
doleak after endovascular repair of abdominal
aortic aneurysm.
J Vasc Surg.
2001;34:98–105.
36. Walker SR, Macierewicz J, Hopkinson BR. En-
dovascular AAA repair: prevention of side
branch endoleaks with thrombogenic sponge.
J Endovasc Surg.
1999;6:350–353.