Back to 2016 Annual Symposium ePosters

Objectives: Multiple endovascular intervention methods have been described for treatment of persistent type II endoleaks (T2EL) causing aneurysm sac growth following endovascular aneurysm repair (EVAR). In the event of a failed endovascular procedure and a persistent T2EL, a general consensus regarding further treatment is lacking and the literature suggests repeated endovascular attempts are rarely successful. Herein, we propose an algorithm for definitive management of type II endoleaks with persistent sac growth following EVAR.
Methods: A retrospective review of 30 patients who underwent treatment for persistent sac growth in the setting of persistent isolated type II endoleaks was performed. Demographic, operative, and outcome data were collected. Intervention methods were determined at the discretion of the operating surgeon. Aneurysmal sac enlargement was defined as a diameter increase > 5 mm, and persistent endoleak was defined as lasting greater than 6 months.
Results: From 2000-2015, 895 EVAR procedures were performed at our institution. Isolated persistent T2EL that caused either pain or sac enlargement were identified in 30 patients. All patients had angiography confirming the endoleaks. 22 patients underwent direct translumbar sac puncture and coiling or Onyx® embolization of the culprit vessels. Endoleaks persisted in 12 patients, 8 with isolated T2EL and concomitant aneurysmal sac growth (mean increase = 5.3%). 6 patients underwent a third embolization procedure; T2EL persisted in 4 patients. Of the 4 persistent ELs, 3 patients were subsequently treated with laparotomy, ligation of lumbar vessels, sac exploration, and sac plication around the endograft. Explantation of the endograft was not necessary. Technical success for this technique was 100%.
Conclusions: We propose a new algorithm for management of patients with type II endoleaks that require intervention. 1) Trans-femoral angiography with coiling or Onyx® embolization of culprit vessels. If that fails to control the endoleak, 2) Direct translumbar percutaneous sac puncture with Onyx® embolization. If these 2 endovascular procedures fail to obtain control of the endoleak, repeat endovascular procedures are not recommended. Endovascular failure should be followed by 3) Laparotomy with surgical ligation of lumbar vessels followed by sac exploration and plication of the sac, leaving the endograft in-situ. This novel surgical technique is well tolerated and has shown excellent short-term results.