Society For Clinical Vascular Surgery

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High rate of Type III Endoleaks after EVAR with Endologix grafts
GEORGIOS TZAVELLAS, MD, Spyridon Monastiriotis, MD, Angela Kokkosis, MD, George Koullias, MD, David Landau, MD, Shang Loh, MD, Apostolos Tassiopoulos, MD.

Objective: Endologix stent grafts were introduced in 2004 and offer some unique advantages over other modular devices. However, a recent communication by the manufacturer indicated higher than expected rates of type III endoleaks (TIIIEL). This study reviewed all patients who underwent EVAR with Endologix grafts in our institution to assess the rate of TIIIEL and secondary interventions.
Methods: Inpatient and outpatient records of all patients who underwent EVAR with Endologix grafts since 2010 at our institution were reviewed. All complications including those that required subsequent re-interventions were recorded. Postoperative complications, reinterventions and outcomes were analyzed.
Results: Between 2011 and 2017, twenty-seven patients underwent EVAR with Endologix grafts in our institution. Six patients (22.2%) developed graft-related complications in the postoperative period (Table 1). Three patients (11.1%) developed Type III endoleaks during follow up: one (AFX graft) with Type IIIa and two (Powerlink with Endurant proximal extension) with combined Type IIIaEL and IIIbEL. The mean interval between the initial procedure and the TIIIEL diagnosis was 31.3 months (range 14-44 months). All patients were treated with relining of the original endograft. Mean follow up after reintervention was 11.4 months (range 1 week-25 months). One patient was noted to have sac enlargement with a new TIIIbEL (different site) after the initial reintervention, and required AUI conversion. The initial endoleak resolved after relining in the other two patients. During the same period, two patients who underwent EVAR with Endologix elsewhere presented with rupture due to type III endoleaks. Both patients were treated by relining (1 Endurant, 1 Endologix); one patient died 9 days postoperatively. TIIIb endoleaks were most commonly seen arising from a fabric defect at the level of the main body bifurcation.
Conclusion: A high rate of TIIIEL was evident in this series of patients, most of whom had a Powerlink or an AFX Vela implant. TIIIELs were identified 2-4 years after the original endograft implantation, thus emphasizing the need for close follow up in these patients. Although the rate of TIIIEL reported by the manufacturer is significantly lower, our results suggest that it could potentially be underreported.
Table 1. Complications and reintervention

Patient NoComplicationType of graftTime to complicationReintervention
1Type IIIa ELAFX36 monthsReline (Endologix)
2Type IIIa EL
Type IIIb
Powerlink, proximal Endurant44 monthsReline (Endurant)
31st Type IIIa EL
2nd Type IIIb EL
AFX, proximal Endurant14 months
24 months
Reline (Endurant)
Reline with AUI (Endurant)
4Limb stenosisAFX21 monthsStent placement
5Delivery system malfunctionAFX0Open conversion
6Type Ia EL,
Limb occlusion
Powerlink54 monthsRefused intervention

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