Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Endoleak management

•An endoleak is defined as persistent blood flow within an aneurysm sac after endovascular aneurysm repair (EVAR).•Although some endoleaks will resolve spontaneously or will not lead to sac expansion, others will require intervention to prevent aneurysm expansion and rupture.•Management should be determined by the endoleak type and the associated risk of sac rupture.•The types of endoleaks are depicted in the Fig. The Society for Vascular Surgery clinical practice guidelines1Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B.M. Lee W.A. Mansour M.A. et al.The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67: 2-77Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar state the following:•Treatment is recommended for type I and III endoleaks (grade 1B evidence level).•Surveillance is recommended for type II endoleaks not associated with aneurysm expansion (grade 1B evidence level).•Treatment is suggested for type II endoleaks associated with aneurysm expansion (grade 2C evidence level).•Open repair is recommended if endovascular intervention has failed to treat a type I or type III endoleak with ongoing aneurysm enlargement (grade 1B evidence level).•Open repair is suggested if endovascular intervention fails to treat a type II endoleak with ongoing aneurysm enlargement (grade 2C evidence level).•Treatment is suggested for ongoing aneurysm expansion even in the absence of a visible endoleak, referred to as endotension or a type V endoleak (grade 2C evidence level).•Treatment is not recommended for a type IV endoleak (grade 2C evidence level). •Type I and III endoleaks expose the aneurysm sac to systemic pressure and are associated with a risk of rupture.2van Marrewijk C. Buth J. Harris P.L. Norgren L. Nevelsteen A. Wyatt M.G. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience.J Vasc Surg. 2002; 35: 461-473Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar•Type II endoleaks will be present in ≤25% of patients at repair.•However, 30% to 50% of type II endoleaks will resolve without intervention.3Lal B.K. Zhou W. Li Z. Kyriakides T. Matsumura J. Lederle F.A. et al.Predictors and outcomes of endoleaks in the Veterans Affairs Open Versus Endovascular Repair (OVER) trial of abdominal aortic aneurysms.J Vasc Surg. 2015; 62: 1394-1404Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar,4Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (175) Google Scholar•The risk factors for persistent type II endoleak include the following5Lo R.C. Buck D.B. Herrmann J. Hamdan A.D. Wyers M. Patel V.I. et al.Risk factors and consequences of persistent type II endoleaks.J Vasc Surg. 2016; 63: 895-901Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar,6Abularrage C.J. Crawford R.S. Conrad M.F. Lee H. Kwolek C.J. Brewster D.C. et al.Preoperative variables predict persistent type 2 endoleak after endovascular aneurysm repair.J Vasc Surg. 2010; 52: 19-24Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar:•Patent inferior mesenteric artery•Number and diameter of patent lumbar arteries•Presence of accessory renal artery or median sacral artery•Ongoing anticoagulation•Limited preexisting sac thrombus volume•Treatment is indicated for significant sac growth (≥5 mm) or with the onset of symptoms attributable to the endoleak.2van Marrewijk C. Buth J. Harris P.L. Norgren L. Nevelsteen A. Wyatt M.G. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience.J Vasc Surg. 2002; 35: 461-473Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar •Sac expansion in the presence of a presumed type II endoleak can result from an occult type I or type III endoleak.•Careful evaluation is required to exclude a type I or III endoleak in all patients with a suspected endoleak.•Dynamic color duplex ultrasound can be a helpful adjunct to evaluate a new or persistent type II endoleak associated with sac enlargement to assess for a positional endoleak or seal zone defect that might not be evident on routine static imaging.•Given the conflicting reports regarding whether a type II endoleak is a benign entity or responsible for late aneurysm-related complications, controversy remains regarding the optimal surveillance and management protocols for type II endoleaks.•Although the current guidelines recommend treatment of a type II endoleak in the presence of symptoms or significant sac growth, recent evidence has suggested that neither survival nor aneurysm-related outcomes will be improved for patients treated for a type II endoleak.7Mulay S. Geraedts A.C.M. Koelemay M.J.W. Balm R. ODYSSEUS Study GroupType 2 endoleak with or without intervention and survival after endovascular aneurysm repair.Eur J Vasc Endovasc Surg. 2021; 61: 779-786Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,8Walker J. Tucker L.Y. Goodney P. Candell L. Hua H. Okuhn S. et al.Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth.J Vasc Surg. 2015; 62: 551-561Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar•A common, but nonvalidated, treatment algorithm for persistent type II endoleak management entails the following4Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (175) Google Scholar,9Wu W.W. Swerdlow N.J. Dansey K. Shuja F. Wyers M.C. Schermerhorn M.L. Surgical treatment patterns and clinical outcomes of patients treated for expanding aneurysm sacs with type II endoleaks after endovascular aneurysm repair.J Vasc Surg. 2021; 73: 484-493Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar:•Transarterial embolization via superior mesenteric or iliac artery access•Transcaval or translumbar embolization if transarterial embolization fails or is not technically feasible•Laparoscopic ligation, sacotomy, or graft explant should endovascular techniques fail•Despite a stepwise treatment approach, the recurrence of a type II endoleak after intervention can be as high as 60%.9Wu W.W. Swerdlow N.J. Dansey K. Shuja F. Wyers M.C. Schermerhorn M.L. Surgical treatment patterns and clinical outcomes of patients treated for expanding aneurysm sacs with type II endoleaks after endovascular aneurysm repair.J Vasc Surg. 2021; 73: 484-493Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar•The evidence comparing the treatment approaches is insufficient to determine whether the high failure rate of endovascular management represents a deviation from a “best practice” algorithm, an inherent deficiency associated with a formulaic, rather than a tailored patient-specific approach, or operator-dependent technical failure.•Prospective randomized trials are needed to evaluate the optimal singular or combined sequential endovascular treatment approach for patients with a type II endoleak and associated sac expansion.•Two systematic reviews have reported higher clinical success rates with translumbar compared with transarterial embolization.4Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (175) Google Scholar,10Guo Q. Zhao J. Ma Y. Huang B. Yuan D. Yang Y. et al.A meta-analysis of translumbar embolization versus transarterial embolization for type II endoleak after endovascular repair of abdominal aortic aneurysm.J Vasc Surg. 2020; 71: 1029-1034Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar•Prospective randomized trials are needed to evaluate the benefit of selective prophylactic aortic side branch embolization and sac embolization for patients at high risk of a type II endoleak.•Two recent small, randomized trials have evaluated concomitant aneurysm sac coiling11Fabre D. Mougin J. Mitilian D. Cochennec F. Garcia Alonso C. Becquemin J.P. et al.Prospective, randomised two centre trial of endovascular repair of abdominal aortic aneurysm with or without sac embolisation.Eur J Vasc Endovasc Surg. 2021; 61: 201-209Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and inferior mesenteric artery embolization12Samura M. Morikage N. Otsuka R. Mizoguchi T. Takeuchi Y. Nagase T. et al.Endovascular aneurysm repair with inferior mesenteric artery embolization for preventing type II endoleak: a prospective randomized controlled trial.Ann Surg. 2020; 271: 238-244Crossref PubMed Scopus (32) Google Scholar for patients deemed at high risk of type II endoleak undergoing EVAR. Early results have suggested that concomitant embolization is associated with a decrease in type II endoleak and enhanced sac volume reduction.•A consensus statement to revisit optimal endoleak nomenclature might reduce misinterpretation by patients, families, and physicians that reference to an endoleak suggests a ruptured aneurysm sac.