Management of type II endoleak after EVAR: Risk assessment and surveillance

Background: Type II endoleak (T2EL) is the most frequently reported complication following endovascular aneurysm repair (EVAR). Although generally considered benign and often self-limiting, spontaneous resolution does not always occur, and secondary intervention may be required. In this study, morphological and morphovolumetric parameters were compared between patients who developed T2EL and those without endoleak, in order to identify predictors of T2EL development in the pre-EVAR period. Additionally, our experience in the management of T2EL was reviewed in the context of the existing literature. Methods: A total of 472 patients who underwent EVAR were initially evaluated. After exclusion of other endoleak types, 408 patients were included in the final analysis, of whom 53 (13%) developed T2EL. The no-endoleak group comprised 355 patients (87%). Overall, T2EL accounted for 45.2% of all detected endoleaks. Primary endpoints were the identification of factors influencing T2EL development and the assessment of morphological and morphovolumetric parameters associated with endoleak formation. Secondary endpoints included secondary intervention rates, as well as post-EVAR mortality and morbidity. Results: No early mortality was observed. The mean follow-up duration was 33.2±21.2 months (median: 25 months; range: 12-99 months). All patients had at least one year of follow-up. Both univariate and multivariate analyses identified age, antiplatelet therapy regimen, inferior mesenteric artery (IMA) diameter, number of patent lumbar arteries, thrombus localisation, and the intraluminal thrombus-to-aneurysm volume ratio as significant predictors of T2EL development. Late mortality for the entire cohort was 23.0%, with cardiac-related causes being the most common (11.0%). Mean intensive care unit stay was 5.2±5.1 hours, and mean hospital stay was 2.6±1.0 days. Conclusion: Although EVAR effectively reduces aneurysm diameter and volume during follow-up, the presence of T2EL may limit this benefit. Lumbar arteries were the most common source of T2EL. An IMA diameter >3 mm, female sex, double antiplatelet therapy, presence of four or more lumbar arteries, absence of coronary artery disease, and thrombus characteristics were associated with increased T2EL risk. D-dimer appears to be a useful biomarker for T2EL detection. Morphovolumetric analysis is more sensitive than maximum diameter measurement in the surveillance of low-flow endoleaks.