Writing in an article published online in the Journal of Vascular Surgery (JVS), John F Charitable, Neal Cayne (both NYU Langone Health, New York, USA), and colleagues conclude that translumbar embolisation is a safe and effective treatment option for type II endoleak with aneurysm growth following endovascular aneurysm repair (EVAR).
The authors add that patients taking antiplatelet medication and those with larger aneurysms at the time of endoleak identification appear to be at increased risk for persistent endoleak and need for subsequent procedures following initial translumbar embolisation. “These patients may require more intensive monitoring and follow-up,” they write.
Charitable, Cayne, et al stress that the presence of an endoleak can compromise aneurysm exclusion after EVAR, with type II endoleaks being the most common iteration and having the potential to cause sac expansion.
In order to investigate the outcomes of translumbar embolisation for type II endoleaks following EVAR, the investigators conducted a retrospective chart review of patients with type II endoleak after EVAR, treated from 2011–2018 at a single academic institution. They detail that treatment indications were the presence of persistent type II endoleak and aneurysm growth ≥5mm, with sac stabilisation being defined as growth ≤5mm throughout the follow-up period.
Charitable, Cayne, and colleagues detail that 30 patients were identified, the majority of whom were men (n=24) with a mean age of 74.3 years (95% confidence interval [CI], 70.9-77.6). The most common comorbidities were hypertension (83.3%) and coronary artery disease (54%), they add.
The researchers detail some key parameters of the study cohort: the mean maximal sac diameter at type II endoleak discovery was 5.8cm (95% CI, 5.4–6.2); the mean time to intervention from endoleak discovery was 33.7±28 months with a mean growth of 0.84cm (95% CI, 0.48–1.2) during that time period; and the mean follow-up time after translumbar embolisation was 19.1 months (95% CI, 11.1–27.2).
A total of 28 patients were treated with cyanoacrylate glue alone, and two were treated with cyanoacrylate glue plus coil embolisation, Charitable, Cayne, et al relay. The authors report in JVS that there was immediate complete endoleak resolution as assessed intraoperatively, and sac stabilisation in 15 cases (15%).
Eleven (36.7%) patients had evidence of persistent type II endoleak on initial imaging after the embolisation procedure, the investigators reveal, noting that additional follow-up indicated eventual sac stabilisation at a mean of 21.3±7.2 months and therefore no need for further intervention.
In the remaining four cases (13.3%), Charitable, Cayne, and colleagues communicate, there was persistent type II endoleak after the initial translumbar embolisation requiring a second intervention. They write that repeat translumbar embolisation stabilised growth in three of these four patients after a mean of 17.6–12.9 months, and that one patient required sacotomy and ligation of lumbar vessels due to continued persistence of the type II endoleak and continued aneurysm growth.
“There were no ischaemic complications related to the embolisation procedures,” Charitable, Cayne, et al note, detailing factors associated with persistent endoleak after initial embolisation were larger aneurysm diameter at the time of initial endoleak identification (p<0.001), and the use of antiplatelet agents (p<0.02). They add that the use of anticoagulation was not a significant risk factor for endoleak recurrence of aneurysm growth after translumbar embolisation.