Spontaneous delayed sealing in selected patients with a primary type-Ia endoleak after endovascular aneurysm repair

Abstract

Objective: Direct additional therapy is advised for type-Ia endoleaks detected on completion angiography after endovascular aneurysm repair (EVAR). Additional intraoperative endovascular procedures are, however, often challenging or not possible, and direct open conversion is unattractive. The results of a selective, conservative strategy for patients with primary type-Ia endoleak has been analysed.

Methods: This was a retrospective, single-centre study (UMC, Utrecht, NL). From 2004 to 2008, all patients with a primary type-Ia endoleak and suitable anatomy for EVAR, stentgraft oversizing ≥15%, and optimal deployment were included. Complications during follow-up were studied and all sequential CTA scans were reviewed. These were compared with the remaining patients, treated during the same period.

Results: Fifteen patients were included (14 male, median age 77, range 67-85) with a median aneurysm diameter of 60 mm (48-80), an aneurysm neck diameter of 26 mm (21-32), a neck length of 29 mm (11-39), and infrarenal angulation of 49° (31-90). One patient suffered rupture 2 days after EVAR - leading to the only AAA-related death. Eight of the 15 type-Ia endoleaks disappeared spontaneously on the first postoperative CTA, obtained within 1 week of EVAR. On the second postoperative CTA, obtained a median of 5 months (1-12) after EVAR, all remaining endoleaks had sealed. One recurrence occurred at 4.85 years. During a median follow-up of 3.3 years, there were five secondary interventions. Compared with controls, there were more secondary (or recurrent) type-1a endoleaks (13% vs. 4%), endograft migrations (13% vs. 3%), sac growths (33% vs. 16%), and secondary interventions (33% vs. 23%). None of these differences however, were statistically significant.

Conclusions: All but one of the primary type-Ia endoleaks sealed spontaneously. Until sealing, the risk of rupture persisted, but subsequently only one recurrence of type-Ia endoleak was seen. In selected patients, a conservative approach for primary type-Ia endoleaks may be justified.

Keywords: Abdominal aortic aneurysm; Endoleak; Endovascular techniques; Secondary intervention.