EVAR reintervention management strategies in contemporary practice

Abstract

It is known that following an endovascular aneurysm repair (EVAR) procedure, patients may experience endoleaks, device migration, stent fractures, graft deterioration, or aneurysm growth that might require a reintervention. In this review management strategies of reinterventions after EVAR in contemporary practice will be discussed. The current endovascular treatment options of Type I endoleak involve securing of the attachment site with percutaneous transluminal balloon angioplasty, stent-graft extension, or placement of a stent at the proximal attachment site. Moreover, the use of endostaples to secure the position of the proximal cuff to the primary endograft have been developed. Type II endoleaks can be managed conservatively if the aneurysm is shrinking or remains stable. Otherwise, reinterventions include transarterial embolization, translumbar embolization, transcaval embolization, direct thrombin injection, and endoscopic or open ligation of the lumbar and mesenteric arteries. There is little debate regarding the treatment of type III endoleaks, including deployement of additional stent graft components to bridge the defect. Endovascular treatment of endotension includes endovascular conversion stent or relining of the stent graft. Alternative options are puncture of the aneurysm sac and removal of the aneurysm sac content. In case of migration large balloon-expandable stents can be used to improve the seal between the components, or devices that deploy staples to secure endovascular grafts to the aortic wall to secure endovascular components together. In conclusion, the first treatment options for reinterventions after EVAR are catheter based nowadays.