Step-by-Step Approach to Management of Type II Endoleaks.

Seventy-five percent of abdominal aortic aneurysms are now treated by endovascular aneurysm repair (EVAR) rather than open repair, given the decreased periprocedural mortality, complications, and length of hospital stay for EVAR compared to the surgical counterpart. An endoleak is a potential complication after EVAR, characterized by continued perfusion of the aneurysm sac after stent graft placement. Type II endoleak is the most common endoleak, and often has a benign course with spontaneous resolution, occurring in the first 6 months after repair. However, these type II endoleaks may result in pressurization of the aneurysm sac and potentially sac rupture. They occur from retrograde collateral blood flow into the aneurysm sac, typically from a lumbar artery or the inferior mesenteric artery. Alternative sources include accessory renal, gonadal, median sacral arteries, and the internal iliac artery. We will discuss our protocol for post-EVAR imaging surveillance and potential type II endoleak treatment strategies, including transarterial, translumbar, transcaval, and perigraft approaches, as well as open surgery.

Type II endoleaks: diagnosis and treatment algorithm.

Elective abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm, symptomatic, or rapidly expanding more than 0.5 cm in 6 months. Seventy-five percent of AAAs today are treated with endovascular aneurysm repair (EVAR) rather than open repair. This is fostered by the lower periprocedural mortality, complications, and length of hospital stay associated with EVAR. However, some studies have demonstrated EVAR to result in higher reintervention rates than with open repair, largely due to endoleaks. Type II is the most common, making up 10-25% of all endoleaks. Type II endoleaks, can potentially enlarge and pressurize the aneurysm sac with a risk of rupture. However, many type II endoleaks spontaneously resolve or never lead to sac enlargement. Imaging surveillance and approaches to management of type II endoleaks are reviewed here.

Percutaneous access planning, techniques and considerations for endovascular aortic repair (EVAR).

Percutaneous endovascular aortic repair (EVAR) has transformed the field of aortic repair. As techniques and devices improve, interventionalists continue to expand the boundaries of what is possible, enabling these life-saving procedures to be performed on a wider range of more technically challenging cases. This article discusses endovascular access considerations for EVAR including; ultrasound guidance, preclose technique, access vessel options, innovative devices, and bailout strategies that interventionalists should be familiar with to optimize patient outcomes.