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Objectives: Though not the most common, type I endoleaks are the most morbid endoleak pathology and typically require immediate treatment when identified. We present our tertiary care center experience with type I endoleaks.
Methods: We conducted a retrospective review of all patients hospitalized and referred for treatment of type I endoleaks between January 2008-May 2015. Data from all procedures (diagnostic and therapeutic) as well as the entire hospital course and any documented follow up were captured and analyzed.
Results: We treated 135 patients with documented type I endoleaks. The average age at presentation was 78.7 years with an average time to treatment of 5.3 years. Seventy-eight percent of patients had type Ia endoleaks, 31% had type Ib endoleaks, with 10% having both proximal and distal fixation pathology. Ninety percent of patients presented with expanding aneurysm sacs, with 27% being symptomatic. The average aneurysm sac growth experienced was 0.8cm with the average maximum sac diameter measuring 7.0cm at the time of treatment. The most commonly treated original device was the AneuRx stent graft (n= 60), followed by the Ancure stent graft found in 13% of patients (n= 18). Computed tomographic angiography (63%), followed by traditional angiography (24%), was mainly used for diagnosis of these endoleaks. Thirty-nine percent of patients presented with concomitant type II endoleaks. Seventy-six percent of patients were able to have complex endovascular treatment of these endoleaks with a combination of proximal cuff placement (n=44), Aptus Endostaples (n= 6), aorto-unilateral iliac stent grafting (n=19), iliac limb extension (n=35), or complete graft relining (n= 1). Twenty-four percent of patients required open repair with either open plication (n=12) or graft explant (n=21). The median length of stay of patients treated was 8 days (+/- 8). Primary technical success was achieved in 90% of patients with an overall clinical success rate of 78%. The overall complication rate was 44% (66% in patients requiring open aortic surgery) with 18 deaths and an average follow up of 1.75 years.
Conclusion: Endoleaks related to fixation pathology present a complex problem. A totally endovascular treatment algorithm is recommended, with open repair reserved as a last resort. A thoughtful follow up protocol to ensure maintenance of adequate proximal and distal seal zones is recommended through a minimum of 5 years post EVAR.