Endoleak following endovascular aortic repair
- Rabih A Chaer, MD
Rabih A Chaer, MD
- Professor of Surgery
- The University of Pittsburgh School of Medicine
- Efthymios Avgerinos, MD
Efthymios Avgerinos, MD
- Associate Professor of Surgery
- University of Pittsburgh School of Medicine
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Following endovascular repair of abdominal aortic aneurysm (AAA), endoleak (all types) has been reported in 20 to 50 percent of patients. Manifestations of endoleak range from asymptomatic to uncontrolled aortic rupture. Endoleaks result from a poor seal at the proximal or distal fixation sites or between the graft components, from patent lumbar vessels, or from the result of graft material failure.
Endoleaks may be identified on completion arteriography at the time of endovascular graft placement or during later follow-up at the time of endograft surveillance imaging. The type of endoleak, classified as type I through type IV, determines its clinical significance and treatment. Some types of endoleak clearly affect short-term and long-term outcomes. There is little controversy that type I and III endoleaks should be treated, but there is debate about the clinical importance of type II endoleak. Reports conflict regarding the optimal timing and type of treatment. Most endoleaks are managed successfully with the placement of additional stents or by using embolization techniques, but sometimes open surgical repair is needed.
The classification and management of endoleaks that result from endovascular repair of the aortic aneurysm will be reviewed here. Types of endovascular devices and endovascular repair of abdominal aorta and thoracic aorta are reviewed separately. (See "Endovascular devices for abdominal aortic repair" and "Endovascular devices for thoracic aortic repair" and "Endovascular repair of abdominal aortic aneurysm" and "Endovascular repair of the thoracic aorta".)
ETIOLOGY AND CLASSIFICATION
For patients with suitable anatomy, an endovascular approach is widely accepted as the preferred initial approach for repair of an infrarenal abdominal aortic aneurysm (AAA) or descending thoracic aortic aneurysm [1-6]. One of the limitations of endovascular repair is the need for ongoing surveillance, primarily to identify type II endoleak, which may require reintervention . (See "Management of asymptomatic abdominal aortic aneurysm" and "Endovascular repair of abdominal aortic aneurysm".)
Successful endovascular repair must completely exclude the aneurysm from the arterial circulation to eliminate the effects of systemic blood pressure on the aneurysm sac, which prevents aneurysm expansion and rupture. Persistent arterial perfusion of the aneurysm sac after endovascular treatment indicates a failure to completely exclude the aneurysm and is defined as endoleak [8,9]. Endoleak is associated with an ongoing risk for aneurysm expansion or rupture.
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- ETIOLOGY AND CLASSIFICATION
- CLINICAL MANIFESTATIONS
- ENDOLEAK MANAGEMENT AFTER EVAR
- Type I endoleak
- - Initial approach to type I endoleak
- - Refractory and late type I endoleak
- Type II endoleak
- - Criteria for treatment
- - Treatment techniques
- Type III endoleak
- Type IV endoleak
- Endoleak of undefined origin
- Alterations to surveillance
- Alterations to antithrombotic therapies
- ENDOLEAK MANAGEMENT AFTER TEVAR
- ENDOLEAK MANAGEMENT AFTER COMPLEX ABDOMINAL ENDOGRAFTING
- PREVENTION STRATEGIES
- SUMMARY AND RECOMMENDATIONS