Frederico Bastos Gonçalves (Utrecht University Medical Center, Utrecht, The Netherlands) reported that, according to the results of a study, conservative management of primary type Ia endoleaks that occur after endovascular aortic aneurysm repair (EVAR) may be feasible in selected patients.
Speaking at the annual meeting of the European Society for Vascular Surgery (18–21 September, Budapest, Hungary), Bastos Gonçalves commented that direct additional therapy is advised if a type IA endoleak is detected on completion angiography during an EVAR procedure. However, he added that there are limitations with the “on table” correction techniques. For example, a proximal cuff would “be useless if deployment was correct” and the use of a hand-mounted, balloon expandable stent was limited by diameter and complexity. Additionally, direct conversion to open surgery was associated with 20–40% mortality and prohibitive for many patients. He noted: “We aim to analyse the results of a conservative strategy for selected patients with primary type IA endoleaks.”
Between August 2004 and December 2008, 383 patients who underwent EVAR at the Utrecht University Medical Center were prospectively included in an institutional database. All patients had suitable anatomy for EVAR, received stent graft oversizing of 10–20%, and received a stent deployed at the optimal position. Information on baseline anatomy, intraoperative findings, and follow-up information were included in the database.
Of these patients, Bastos Gonçalves reported, 15 patients had a type IA endoleak (detected intraoperatively). One patient suffered a ruptured aneurysm two days after the EVAR, but 53% of the remaining patients did not have evidence of the endoleak on the postoperative CT angiography one week after EVAR. By five months, all endoleaks had sealed spontaneously and there were no recurrences during the median follow-up of 27 months. However, by five years, one patient had a recurrence, two patients had been converted to open surgery, one patient was converted to aorti-uni-iliac, and two patients received a proximal cuff. There were no late aneurysm-related deaths.
Bastos Gonçalves said: “The take-home message is that if the anatomy is suitable for EVAR, the sizing is done correctly, and the stent graft is deployed at the optimal position, most primary type IA endoleaks will seal spontaneously.” However, the risk of rupture persists until the sealing occurs. He concluded that a conservative approach to primary type IA endoleaks “may be justified” in a selected subgroup “at possible cost of more complications during follow-up”.
Bastos Gonçalves spoke to Vascular News about the study.
In which subgroup is spontaneous sealing of type IA endoleak most likely to occur?
In patients with irregular thrombus or calcification in the neck or under oral anticoagulation, given adequate endograft positioning, sufficient neck length and recommended oversizing.
In whom is conservative management of type IA endoleaks not advisable?
In patients with unfavourable proximal anatomy, particularly those with a short and/or very angulated proximal landing zone. Also, a subjective analysis of the endoleak may suggest a high or low flow. A high-flow endoleak suggests a serious problem at the proximal attachment, and in those cases a conservative strategy is not recommended.
What further research needs to be done in this area?
It is important to determine if newer devices (third or fourth generation) will behave in a similar fashion to the relatively outdated devices used during the study period. It is possible that primary proximal endoleaks may be less frequent with these devices, due to their improved conformability at the proximal attachment.