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 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
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
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
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
Type III endoleak
Cannot be managed conservatively
Endograft defect or separation of components reperfuses aneurysm sac with systemic blood
Invariably requires intervention
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
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
Related Anatomy
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Related Differential Diagnoses
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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 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
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
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
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
Type III endoleak
Cannot be managed conservatively
Endograft defect or separation of components reperfuses aneurysm sac with systemic blood
Invariably requires intervention
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
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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