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KEY FACTS
Terminology
Procedure
Post Procedure
TERMINOLOGY
Definitions
- Endoleak: Persistent perfusion of excluded aneurysm sac after endograft placement
- Type I: Perfusion of aneurysm sac via incomplete/ineffective seal at endograft attachment site
- Type IA: Originates at proximal attachment site
- e.g., infrarenal attachment of upper margin of bifurcated abdominal aortic endograft body
- Type IB: Originates at distal attachment site
- e.g., common iliac artery attachment of limb of bifurcated abdominal aortic endograft
- Type IA: Originates at proximal attachment site
- Type II: Perfusion of aneurysm sac via arterial branches arising from excluded aortic segment
- Similar pathophysiology to arteriovenous malformation
- Patent arterial side branches continue to perfuse residual abdominal aortic aneurysm (AAA) sac
- Endoleak within AAA sac acts as nidus; endoleak repair requires elimination of nidus
- Most common endoleak type
- Similar pathophysiology to arteriovenous malformation
- Type III: Perfusion of aneurysm sac due to mechanical problem with endograft
- Type IIIA: Junctional leak or modular disconnection of graft components
- Type IIIB: Fabric disruption (tear in fabric)
- Type IV: Perfusion of aneurysm sac due to graft fabric porosity; rarely seen with current endografts
- Usually transient; may be related to aggressive intraprocedural anticoagulation
- Type V: Continued sac enlargement without identifiable endoleak; a.k.a. endotension
- May represent endoleak that cannot be identified
- Type I: Perfusion of aneurysm sac via incomplete/ineffective seal at endograft attachment site
- Endoleak: Persistent perfusion of excluded aneurysm sac after endograft placement
Expectant Management of Endoleaks
- Type I endoleak
- Cannot be managed conservatively
- Represents direct communication with systemic blood flow; high risk of rupture if untreated
- Invariably requires intervention
- Represents direct communication with systemic blood flow; high risk of rupture if untreated
- Cannot be managed conservatively
- Type II endoleak
- Optimal management remains controversial
- Some investigators advocate immediate repair
- Other investigators recommend expectant management until aneurysm shows enlargement
- 17% show enlargement if early type II endoleak
- 55% of aneurysms show enlargement with persistent (≥ 6 months) type II endoleak
- Typically has relatively benign course
- Many seal spontaneously over time; conservative management usually justified
- 14-25% incidence after endovascular aneurysm repair (EVAR) at 1 month; 10.2% after 1 year
- Many seal spontaneously over time; conservative management usually justified
- Optimal management remains controversial
- Type III endoleak
- Cannot be managed conservatively
- Endograft defect or separation of components reperfuses aneurysm sac with systemic blood
- Invariably requires intervention
- Endograft defect or separation of components reperfuses aneurysm sac with systemic blood
- Cannot be managed conservatively
- Type IV endoleak
- Managed conservatively; occurs infrequently
- Much less frequent with current endograft technology, improved fabrics
- Type V endoleak
- Usually managed conservatively/observed
- May require intervention if continued sac enlargement, despite lack of endoleak on imaging
- Type I endoleak
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
OUTCOMES
Complications
Expected Outcomes
Selected References
- Oderich GS et al: Reporting standards for endovascular aortic repair of aneurysms involving renal-mesenteric arteries. J Vasc Surg. 73(1S):4S-52S 2021
- Tao S et al: Percutaneous contrast-enhanced ultrasound-guided transabdominal sac embolization is an effective technique for treating complicated type II endoleaks after endovascular aneurysm repair. J Vasc Surg. 75(6):1918-25, 2022
- Williams AB et al: Imaging modalities for endoleak surveillance. J Med Radiat Sci. 68(4):446-52, 2021
- Abdul Jabbar A et al: Percutaneous endovascular abdominal aneurysm repair: state-of-the art. Catheter Cardiovasc Interv. 95(4):767-82, 2020
- Ameli-Renani S et al: Secondary endoleak management following TEVAR and EVAR. Cardiovasc Intervent Radiol. 43(12):1839-54, 2020
- Daye D et al: Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management. Cardiovasc Diagn Ther. 8(Suppl 1):S138-56, 2018
- Seike Y et al: Influence of warfarin therapy on occurrence of postoperative endoleaks and aneurysm sac enlargement after endovascular abdominal aortic aneurysm repair. Interact Cardiovasc Thorac Surg. 24(4):615-8, 2017
- Tanious A et al: Endovascular management of proximal fixation loss using parallel stent grafting techniques to preserve visceral flow. Ann Vasc Surg. 42:169-75, 2017
- Yu H et al: Comparison of type II endoleak embolizations: embolization of endoleak nidus only versus embolization of endoleak nidus and branch vessels. J Vasc Interv Radiol. 28(2):176-84, 2017
- Yang RY et al: Direct sac puncture versus transarterial embolization of type II endoleaks: an evaluation and comparison of outcomes. Vascular. 25(3):227-33, 2017
- Böckler D et al: Multicenter Nellix EndoVascular Aneurysm Sealing system experience in aneurysm sac sealing. J Vasc Surg. 62(2):290-8, 2015
- Katsargyris A et al: Endostaples: are they the solution to graft migration and type I endoleaks? J Cardiovasc Surg (Torino). 56(3):363-8, 2015
- Abularrage CJ et al: Improved results using Onyx glue for the treatment of persistent type 2 endoleak after endovascular aneurysm repair. J Vasc Surg. 56(3):630-6, 2012
- Chaar CI et al: Delayed open conversions after endovascular abdominal aortic aneurysm repair. J Vasc Surg. 55(6):1562-9, 2012
- Patatas K et al: Static sac size with a type II endoleak post-endovascular abdominal aortic aneurysm repair: surveillance or embolization? Interact Cardiovasc Thorac Surg. 15(3):462-6, 2012
- Sarac TP et al: Long-term follow-up of type II endoleak embolization reveals the need for close surveillance. J Vasc Surg. 55(1):33-40, 2012
- Cao P et al: Endoleak after endovascular aortic repair: classification, diagnosis and management following endovascular thoracic and abdominal aortic repair. J Cardiovasc Surg (Torino). 51(1):53-69, 2010
- Cerna M et al: Endotension after endovascular treatment of abdominal aortic aneurysm: percutaneous treatment. J Vasc Surg. 50(3):648-51, 2009
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References
Tables
Tables
KEY FACTS
Terminology
Procedure
Post Procedure
TERMINOLOGY
Definitions
- Endoleak: Persistent perfusion of excluded aneurysm sac after endograft placement
- Type I: Perfusion of aneurysm sac via incomplete/ineffective seal at endograft attachment site
- Type IA: Originates at proximal attachment site
- e.g., infrarenal attachment of upper margin of bifurcated abdominal aortic endograft body
- Type IB: Originates at distal attachment site
- e.g., common iliac artery attachment of limb of bifurcated abdominal aortic endograft
- Type IA: Originates at proximal attachment site
- Type II: Perfusion of aneurysm sac via arterial branches arising from excluded aortic segment
- Similar pathophysiology to arteriovenous malformation
- Patent arterial side branches continue to perfuse residual abdominal aortic aneurysm (AAA) sac
- Endoleak within AAA sac acts as nidus; endoleak repair requires elimination of nidus
- Most common endoleak type
- Similar pathophysiology to arteriovenous malformation
- Type III: Perfusion of aneurysm sac due to mechanical problem with endograft
- Type IIIA: Junctional leak or modular disconnection of graft components
- Type IIIB: Fabric disruption (tear in fabric)
- Type IV: Perfusion of aneurysm sac due to graft fabric porosity; rarely seen with current endografts
- Usually transient; may be related to aggressive intraprocedural anticoagulation
- Type V: Continued sac enlargement without identifiable endoleak; a.k.a. endotension
- May represent endoleak that cannot be identified
- Type I: Perfusion of aneurysm sac via incomplete/ineffective seal at endograft attachment site
- Endoleak: Persistent perfusion of excluded aneurysm sac after endograft placement
Expectant Management of Endoleaks
- Type I endoleak
- Cannot be managed conservatively
- Represents direct communication with systemic blood flow; high risk of rupture if untreated
- Invariably requires intervention
- Represents direct communication with systemic blood flow; high risk of rupture if untreated
- Cannot be managed conservatively
- Type II endoleak
- Optimal management remains controversial
- Some investigators advocate immediate repair
- Other investigators recommend expectant management until aneurysm shows enlargement
- 17% show enlargement if early type II endoleak
- 55% of aneurysms show enlargement with persistent (≥ 6 months) type II endoleak
- Typically has relatively benign course
- Many seal spontaneously over time; conservative management usually justified
- 14-25% incidence after endovascular aneurysm repair (EVAR) at 1 month; 10.2% after 1 year
- Many seal spontaneously over time; conservative management usually justified
- Optimal management remains controversial
- Type III endoleak
- Cannot be managed conservatively
- Endograft defect or separation of components reperfuses aneurysm sac with systemic blood
- Invariably requires intervention
- Endograft defect or separation of components reperfuses aneurysm sac with systemic blood
- Cannot be managed conservatively
- Type IV endoleak
- Managed conservatively; occurs infrequently
- Much less frequent with current endograft technology, improved fabrics
- Type V endoleak
- Usually managed conservatively/observed
- May require intervention if continued sac enlargement, despite lack of endoleak on imaging
- Type I endoleak
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
OUTCOMES
Complications
Expected Outcomes
Selected References
- Oderich GS et al: Reporting standards for endovascular aortic repair of aneurysms involving renal-mesenteric arteries. J Vasc Surg. 73(1S):4S-52S 2021
- Tao S et al: Percutaneous contrast-enhanced ultrasound-guided transabdominal sac embolization is an effective technique for treating complicated type II endoleaks after endovascular aneurysm repair. J Vasc Surg. 75(6):1918-25, 2022
- Williams AB et al: Imaging modalities for endoleak surveillance. J Med Radiat Sci. 68(4):446-52, 2021
- Abdul Jabbar A et al: Percutaneous endovascular abdominal aneurysm repair: state-of-the art. Catheter Cardiovasc Interv. 95(4):767-82, 2020
- Ameli-Renani S et al: Secondary endoleak management following TEVAR and EVAR. Cardiovasc Intervent Radiol. 43(12):1839-54, 2020
- Daye D et al: Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management. Cardiovasc Diagn Ther. 8(Suppl 1):S138-56, 2018
- Seike Y et al: Influence of warfarin therapy on occurrence of postoperative endoleaks and aneurysm sac enlargement after endovascular abdominal aortic aneurysm repair. Interact Cardiovasc Thorac Surg. 24(4):615-8, 2017
- Tanious A et al: Endovascular management of proximal fixation loss using parallel stent grafting techniques to preserve visceral flow. Ann Vasc Surg. 42:169-75, 2017
- Yu H et al: Comparison of type II endoleak embolizations: embolization of endoleak nidus only versus embolization of endoleak nidus and branch vessels. J Vasc Interv Radiol. 28(2):176-84, 2017
- Yang RY et al: Direct sac puncture versus transarterial embolization of type II endoleaks: an evaluation and comparison of outcomes. Vascular. 25(3):227-33, 2017
- Böckler D et al: Multicenter Nellix EndoVascular Aneurysm Sealing system experience in aneurysm sac sealing. J Vasc Surg. 62(2):290-8, 2015
- Katsargyris A et al: Endostaples: are they the solution to graft migration and type I endoleaks? J Cardiovasc Surg (Torino). 56(3):363-8, 2015
- Abularrage CJ et al: Improved results using Onyx glue for the treatment of persistent type 2 endoleak after endovascular aneurysm repair. J Vasc Surg. 56(3):630-6, 2012
- Chaar CI et al: Delayed open conversions after endovascular abdominal aortic aneurysm repair. J Vasc Surg. 55(6):1562-9, 2012
- Patatas K et al: Static sac size with a type II endoleak post-endovascular abdominal aortic aneurysm repair: surveillance or embolization? Interact Cardiovasc Thorac Surg. 15(3):462-6, 2012
- Sarac TP et al: Long-term follow-up of type II endoleak embolization reveals the need for close surveillance. J Vasc Surg. 55(1):33-40, 2012
- Cao P et al: Endoleak after endovascular aortic repair: classification, diagnosis and management following endovascular thoracic and abdominal aortic repair. J Cardiovasc Surg (Torino). 51(1):53-69, 2010
- Cerna M et al: Endotension after endovascular treatment of abdominal aortic aneurysm: percutaneous treatment. J Vasc Surg. 50(3):648-51, 2009
