Operative Management of Type II Endoleaks After Aortic Endovascular Repair
Endovascular aneurysm repair (EVAR) is associated with decreased periprocedural mortality, complications, and length of hospital stay compared to open repair.
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Operative Management of Type II Endoleaks After Aortic Endovascular Repair Anna Maria Ierardi, Filippo Pesapane, Francesca Patella, Enrico Maria Fumarola, Salvatore Alessio Angileri, Mario Petrillo, Matteo Crippa, and Gianpaolo Carrafiello 9.1
Introduction
Endoleaks (ELs) are the most common complications after endovascular aneurysm repair (EVAR), with an incidence that varies between 10% and 50% [1–4]. They are defined as persistent flow within the excluded aneurysm sac and the graft [1–4]. Endoleaks are classified according to the underlying etiology and localization [5, 6]. The risk of rupture of the aneurysmatic sac depends on the type and persistency of endoleaks. The type II endoleak (T2EL) is the most common form and occurs in about 20–30% of patients after treatment, persisting in 10–15% of patients after 6 months [3]. T2EL occurs when a retrograde flow of blood supplies the aneurysm sac through branch vessels such as lumbar arteries or a patent inferior mesenteric artery (IMA) [4]. T2EL usually has a complex architecture because it should be featured by more than one inflow and
A. M. Ierardi · S. A. Angileri · M. Petrillo G. Carrafiello (*) Department of Health Sciences, Diagnostic and Interventional Radiology, San Paolo Hospital, University of Milan, Milan, Italy e-mail: [email protected] F. Pesapane · F. Patella · E. M. Fumarola Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy M. Crippa Surgery Department, San Paolo Hospital, University of Milan, Milan, Italy © Springer Nature Switzerland AG 2019 Y. Tshomba et al. (eds.), Visceral Vessels and Aortic Repair, https://doi.org/10.1007/978-3-319-94761-7_9
outflow vessel, which communicates through a channel [5]. For this reason, a further differentiation of T2EL was proposed: type IIA, when it is related to only one patent branch, and type IIB, when it is complex with two or more patent branches and creating a flow-through situation [4]. Fifty percent of type II ELs resolve spontaneously, 10–15% are persistent on long-term follow-up, and recurrent T2EL develop in 5–10% [2, 4, 7, 8]. A conservative approach with regular followup is accepted for stable T2EL [9, 10], whereas treatment of T2EL is normally required when the aneurysm sac diameter increases more than 5 mm between sequential Computed Tomography (CT) follow-up examinations, because this is indicative of high sac pressure [3]. In the past, T2EL were usually treated surgically, both with graft explantation and with retroperitoneal ligation of collateral feeding vessels [5]. These invasive methods require hospital admission and they increase morbidity of surgery [11]. For this reason, over the years, new less invasive techniques for the treatment of T2EL have made their way through. Nowadays, the most common treatment for patients with T2EL is transarterial embolization (TAE), with the aim of occluding the feeding arteries and/or the EL nidus [12]. In order to achieve successful embolization, the inflow vessels and the channel(s) need to be em
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