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Persistent or delayed type 2 endoleak predicts aneurysm sac growth and late reintervention
Jeremy Herrmann, BS1, Ruby C. Lo, MD1, Mark Wyers, MD1, Virendra I. Patel, MD2, Mark F. Fillinger, MD3, Marc Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Massachusetts General Hospital, Boston, MA, USA, 3Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
OBJECTIVES
Type 2 endoleaks (T2) commonly occur following EVAR. However their clinical significance remains controversial. We determined risk factors for T2 and their impact on adverse outcomes.
METHODS
We performed a retrospective study using the Vascular Study Group of New England (VSGNE) AAA dataset. Patients were subdivided into 2 groups: 1) those with no T2 or transient T2 (lasting <6 months post-operatively) and 2) persistent T2 (lasting >6 months post-operatively) or delayed T2 (no endoleak at completion of case). Patients with other endoleak types were excluded. Multivariable analysis was used to identify independent predictors of persistent or delayed T2. Kaplan-Meier analysis was used to evaluate long-term survival. Multivariable Cox regression analysis identified predictors of late re-intervention and survival.
RESULTS
Of 2757 patients who underwent EVAR, 1782 patients had follow-up endoleak documentation. Among these, we identified 1349 patients in group 1 (80% men, 1046 no leak, 303 transient leak) and 245 in group 2 (78% men, 62 persistent leak, 183 delayed leak). Group 2 patients were older (75±8 vs. 73±8 years, P<.001) and less likely to have COPD (27% vs. 37%, P=.004) or be on aspirin (65% vs. 72%, P=.012). More patients in group 2 underwent graft extension (14% vs. 7%, P=.003). In multivariable analysis, smoking history (OR 0.6, 95% CI 0.4-0.8 , P=.005) and aspirin use (OR 0.6, 95% CI 0.5-0.9, P=.004) were protective against persistent/delayedT2, while bilateral hypogastric artery coiling was predictive (OR 8.3, 95% CI 2.8-24.9, P<.001). Aneurysm sac growth was more common in group 2 among 202 patients with available follow-up data (38% vs. 15%, P=.001). Of 153 reinterventions, 90 occurred after discharge. Preoperative hypertension (HR 3.3, 95%CI 1.2-9.0, P=.022) and persistent/delayed T2 were predictive of post-discharge reintervention (HR 2.1, 95% CI 1.2-3.5, P=.008). Persistent/delayed T2 did not affect late survival (HR 1.3, 95%CI 0.9-2.0, P=.130).
CONCLUSION
Bilateral hypogastric artery coiling correlates with persistent/delayed T2, while aneurysm size and gender do not. Persistent/delayed T2 is associated with increased risk of sac growth and reintervention. This reinforces the need for continued surveillance of patients with persistent/delayed T2 and may be cause for prophylactic intervention.
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