Management of Endoleaks

Abstract

The management of endoleaks remains an inherent challenge to endovascular aneurysm repair (EVAR), particularly as evolving techniques and devices have allowed treatment of increasingly complex aneurysm anatomy. Endovascular techniques are the favored modality for endoleak repair and include techniques to bridge the endoleak defector and embolize the endoleak nidus and inflow/outflow vessels. Conversion to surgical repair remains the definitive option in cases where less invasive methods have failed or are precluded. In this article, the authors review evidence on the indications, approach, and outcomes of current techniques for endoleak management.

Keywords: embolization; endoleak; endovascular aneurysm repair; interventional radiology.

Fig. 1

Type II endoleak treated with transarterial embolization. (a) Computed tomography angiogram (CTA) performed ∼3 years following EVAR demonstrates contrast opacification of the aneurysm sac (arrow) on arterial phase imaging and interval increased aneurysm sac diameter compared with prior CTA (not shown). (b) Arteriogram of the inferior mesenteric artery (IMA) demonstrates opacification of a type II endoleak (arrowhead) via the middle colic artery. (c) Selective arteriogram of the endoleak via a microcatheter better delineates endoleak anatomy. (d) Postembolization unsubtracted arteriogram shows coils in the endoleak sac (arrow). (e) Postembolization subtracted angiogram shows no residual filling of the endoleak sac.

Fig. 2

Type II endoleak treated with translumbar embolization. (a) CTA performed ∼2 years following EVAR demonstrates contrast opacification of the aneurysm sac on arterial phase imaging (arrow). (b) Frontal fluoroscopic image demonstrates access needle trajectory using left translumbar approach (arrow). (c) Arteriogram via the access needle delineates the endoleak sac anatomy with opacification of bilateral lumbar arteries (black arrows) and the median sacral artery (white arrow). (d) Postembolization frontal fluoroscopic image demonstrates coils within the endoleak sac (arrow).

Fig. 3

Type III endoleak treated with aorto-uni-iliac graft, left iliac limb occluder, and femoral–femoral bypass graft. (a) Arteriogram demonstrates type III endoleak (arrow) arising from the junction of the aortic and left iliac components of the stent graft. (b) Arteriogram demonstrates pre-deployment positioning of an aorto-right uni-iliac stent graft with left iliac limb occluder. (c) Postprocedural CTA demonstrates opacified right iliac limb stent graft, left iliac limb occlude (arrow), and no residual contrast opacification of the aneurysm lumen.