Polling Station

Poll 01/08/2019 – 31/08/2019

The Type II Endoleak

Patient’s characteristics

 

Gender: Male

Age: 68 years old

Comorbidity: Arterial hypertension, active smoker

Underwent EVAR 2 years ago

Symptoms:  None

DUS/CT A: Aneurysm sac growth > 7mm compared to last CT scan with evidence of type II Endoleak (Inferior mesenteric artery)

Question #1

Do you consider type II endoleaks after EVAR a major complication?
  • Yes

  • No

The expert: Univ. Prof. Dr. med Nikolaos Tsilimparis, FEBVS, FACS
Type II endoleaks represent a calculated event occurring in approximately 15% of EVAR cases. 60% of them will resolve within 6months. Endoleaks Type II could lead to sac enlargement in 50% of the cases if they prove to persist after 6 months. That means that of 100 EVAR patients about 3 patients will experience sac enlargement because of a type II Endoleak and the risk that they eventually rupture is below 1%. In presence of Type II endoleak however I make sure to make my surveillance more strict.
Question #2

Would you perform a lumbar or mesenteric artery embolization prior to EVAR in order to reduce the risk for a type II endoleak?
  • Selectively

  • Routinely

  • Never

The expert: Univ. Prof. Dr. med Nikolaos Tsilimparis, FEBVS, FACS
I rarely perform preoperative lumbar or mesenteric embolization to prevent a type II Endoleak, given the low rate of secondary aneurysm growth and the fact that one can easily go back and embolize to exclude the endoleak. I am more prone to preoperative embolization of accessory renal arteries with offset from the aneurysm sac or hypogastric artery branches during implantation of iliac side-branch devices in the superior gluteal artery, because these are often very difficult to get access to secondarily.
Question #3

Which is your main criterion for the treatment of an asymptomatic type II endoleak
  • Aneurysm sac growth more than 10 mm

  • Aneurysm sac growth more than 5 mm

  • Persistence more than 6 months

  • I would never treat an asymptomatic type II endoleak

The expert: Univ. Prof. Dr. med Nikolaos Tsilimparis, FEBVS, FACS
Aneurysm growth is almost exclusively the reason I would start treating a type II endoleak. Important is however not to only look at the growth rate to the last CT-scan but also consider the growth over years. Aneurysms with type II Endoleak post EVAR tend to grow slowly (2-3mm/ 6 months) and if one does not compare it with the first post-implantation CT-scan, a significant secondary aneurysm growth may be missed.
Question #4

Which would be your primary treatment option for an asymptomatic type II endoleak?
  • Surgery

  • Endovascular

The expert: Univ. Prof. Dr. med Nikolaos Tsilimparis, FEBVS, FACS
I believe surgery could be considered in very few cases as a primary treatment option, if for example there is a patent inferior mesenteric artery which for some reason cannot be reached over the superior mesenteric artery. I would in this case opt for a laparoscopic IMA ligation.
Question #5

Which would be your primary endovascular strategy for an asymptomatic type II endoleak?
  • Transarterial embolization

  • Transcaval embolization

  • Embolization with puncture of the aneurysm sac

The expert: Univ. Prof. Dr. med Nikolaos Tsilimparis, FEBVS, FACS
For endoleaks from the inferior mesenteric artery, the transarterial route over the superior mesenteric artery and the Riolan Anastomosis would be my first choice. In cases of endoleaks from the lumbar arteries, I usually evaluate the route transarterially with a selective angiography from the iliacs. If there are one or two major lumbars easy to access, I would first perform transarterial occlusion of these lumbars. However in most cases, it a collateral network that end in multiple lumbars. Therefore I have moved more and more to primary transcaval embolization, getting access to the sac and performing either selective lumbar embolization if possible, or alternatively coil- and liquid-embolization of the endoleak.
Question #6

Would you treat a postoperative type II endoleak in case of a ruptured aneurysm?
  • Yes

  • No

The expert: Univ. Prof. Dr. med Nikolaos Tsilimparis, FEBVS, FACS
To be honest I have never experienced a persisting type II endoleak post EVAR for ruptured aneurysm, that was hemodynamically relevant after aneurysm exclusion. The hypotension and the retroperitoneal hematoma applying local pressure at the retroperitoneal space are presumably sufficient to stop back-bleeding of lumbar arteries in the aneurysm sac. I would only intervene if the patient was hemodynamically unstable post EVAR and had a verified type II endoleak.