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Radiology

Management of Endoleaks After Elective Infrarenal Aortic Endovascular Aneurysm RepairA Review

To identify the key insights or developments described in this article

1 Credit CME

JAMA Surgery

Published Online: July 26, 2023

Review

Article Information and Disclosures

Sebastian Cifuentes, MD¹;

Bernardo C. Mendes, MD¹;

Armin Tabiei, MS¹;

Salvatore T. Scali, MD²;

Gustavo S. Oderich, MD³;

Randall R. DeMartino, MD, MS¹

Author Affiliations

¹Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
²Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
³Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston

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Abstract

Importance Endovascular aneurysm repair (EVAR) is the dominant treatment strategy for abdominal aortic aneurysms, encompassing 80% of all repairs in the United States. Endoleaks are ubiquitous and affect 30% of patients treated by EVAR, potentially leading to sac enlargement and increased risk of rupture. The care of EVAR patients requires long-term surveillance by a multidisciplinary team. Accordingly, physicians should be familiar with the fundamentals of endoleak management to achieve optimal outcomes, including timely referral for remediation or providing counseling and reassurance when needed.

Observations PubMed and the Cochrane database were searched for articles published between January 2002 and December 2022 in English, addressing epidemiology, diagnosis, and management of endoleaks after EVAR. Endoleaks can be detected intraoperatively or years later, making lifelong surveillance mandatory. Type I and III have the highest risk of rupture (7.5% at 2 years and 8.9% at 1 year, respectively) and should be treated when identified. Intervention should be considered for other types of endoleak when associated with aneurysm sac growth larger than 5 mm based on current guidelines. Type II endoleaks are the most common, accounting for 50% of all endoleaks. Up to 90% of type II endoleaks resolve spontaneously or are not associated with sac enlargement, requiring only observation. Although the risk of rupture is less than 1%, cases that require reintervention are challenging. Recurrence is common despite endovascular treatment, and rupture can occur without evidence of sac growth. Type IV endoleaks and endotension are uncommon, are typically benign, and primarily should be observed.

Conclusions and Relevance Endoleak management depends on the type and presence of sac expansion. Type I and III endoleaks require intervention. Type II endoleaks should be observed and treated selectively in patients with significant sac expansion. Since endoleaks can appear any time after EVAR, at least 1 contrast-enhanced computed tomographic angiogram or duplex ultrasound by an experienced laboratory is recommended every 5 years.

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Article Information

Accepted for Publication: May 20, 2023.

Published Online: July 26, 2023. doi:10.1001/jamasurg.2023.2934

Corresponding Author: Randall R. DeMartino, MD, MS, Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, 200 First St SW, Gonda Building 4th, Rochester, MN 55905 (demartino.randall@mayo.edu).

Conflict of Interest Disclosures: Dr Mendes reported advisory board fees from Medtronic, speaking fees from Cook Medical, and grants from Cook Medical and WL Gore all paid to his institution outside the submitted work. Dr Oderich reported research grants from WL Gore and GE HealthCare; consulting fees for WL Gore, Cook Medical, and GE HealthCare; serving on a scientific advisory board for Centerline Biomedical; and speaking fees from Gore Medical outside the submitted work. No other disclosures were reported.

Additional Contributions: We appreciate the excellent contribution of David Factor, MS, Mayo Foundation for Medical Education and Research, who created the illustrations for this article. He was not compensated for his contribution besides salary.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.