Prevention of type II endoleaks: results of a study including 1000 patients

Aim: The incidence for type II endoleaks (T2E) reported in literature varies between 10% and 20% but their natural history is still unclear. The aim of this study was to retrospectively evaluate our single centre experience of approximately 1000 patients treated with endovascular aneurysm repair (EVAR) to determine the role of T2Es in mid and long term failure and to optimize their management. Methods: Baseline characteristics, operative and follow-up data of consecutive patients undergoing EVAR at our Institution were prospectively collected in a dedicated database. Patients with a demonstrated type II endoleak at the followup were divided in two groups depending on the spontaneous regression of the endoleak. We compared baseline characteristics, mortality, relation to aneurysm sac evolution, association with type I or III endoleaks and reintervention. The incidence of recurrent T2Es (defined as newly onset endoleaks after a surgical, trans-lumbar or trans-arterial treatment) was also evaluated to define a proper management of these complications. Results: From March 1999 to May 2014, 943 consecutive patients with an aortic or aorto-iliac aneurysms were treated with EVAR. During the follow-up 260 patients had a T2E. Out of these 260 patients, 99 had a spontaneous regression of the endoleak (38.1%) and were defined as Group 1 while 161 had a persistent-T2E (61.9%) and were defined as Group 2. The mean regression time of T2Es was 26.8 months (±21.8) with a median value of 18 months (12-36). During follow-up, an aneurysm sac enlargement >5 mm was found in 10 patients (10.4%) in Group 1 compared with 37 (25.2%) in Group 2 (P<0.001) with a consequent increase in the rate of reinterventions (18.2% vs. 30.4%) for the second group (P<0.001). Adjusted analysis showed an increase risk of persistent-T2Es for age over 80 years (OR, 1.5: CI, 1.0-2.2; P=0.028), hypertension (OR, 1.5: CI, 1.0-2.3; P=0.043), ASA HI and TV (OR, 1.8: CI, 1.3-2.5; P<0.001) and presence of T2E at the completion angiography (OR, 1.5: CI, 1-2.2; P=0.031). Kaplan-Meier curves showed a significant decrease in the overall survival rate for patients presenting a persistent T2E (P=0.041). Conclusion: Persistent T2Es are related with higher mortality, sac enlargement and reinterventions rates. As their treatment appears to be often unsuccessful, the identification of subclasses of patients at risk may alter the treatment option.