International Cross-Sectional Survey on Management of Type II Endoleak and the Role of Preemptive Embolization

BACKGROUND: Type II endoleaks (TIIELs) commonly occur following endovascular aneurysm repair (EVAR). There is a lack of unified consensus regarding the management of TIIEL. Preemptive embolization is a potential method to reduce the risk for TIIEL, but its role is debated. We performed a survey among aortic experts internationally to assess perspectives on TIIEL management and the role of preemptive embolization. METHODS: A questionnaire was prepared covering aspects on effect of TIIEL on EVAR outcome, strategies to manage TIIEL, and attitudes toward preemptive embolization techniques. The questionnaire was distributed using an online platform among vascular specialists across 80 specialized aortic centers worldwide. RESULTS: Of 80 survey recipients, 56 (70%) responded. Only 12% of participants did not believe TIIEL to affect the durability of EVAR. Nearly 82.2% of respondents believed TIIEL increases the likelihood of reintervention. One-quarter agreed that TIIEL increases aortic-related mortality post-EVAR. For established TIIEL, 12% find "any sac expansion" to be an indication for intervention, while 41% would intervene at >5 mm sac expansion, and 52% at >10 mm sac expansion. Majority (63%) perform selective embolization in this setting. Only 3.6% of participants reported routinely conducting preemptive embolization in over 30% of their EVAR cases, while 42.9% never performed this procedure, and 53.6% performed preemptive embolization in <30% of cases. A substantial 76.8% believed that existing literature lacked sufficient evidence to support the integration of preemptive embolization into their clinical practice. Additionally, almost 90% expressed interest in participating in a multicenter randomized controlled trial evaluating the safety and efficacy of preemptive embolization. CONCLUSION: Management of TIIEL is highly diverse among aortic experts. There is a need for further evidence on when and how to best treat TIIEL, as well as robust studies with long-term data to assess the potential role of preemptive embolization in increasing the durability of EVAR.