Type II Endoleak and Sac Dynamics After Endovascular Repair of Ruptured Abdominal Aortic Aneurysm

Objective Endovascular aneurysm repair is a Class I recommendation for ruptured abdominal aortic aneurysm, yet guidance for managing a postoperative Type II endoleak is extrapolated from elective repair data. Because the rupture site is not sealed by the endograft, branch backflow into the sac may sustain hemorrhage in the acute phase and pressurization of an uncontained sac over the longer term. We evaluated the long-term clinical trajectory of Type II endoleak after endovascular repair of ruptured abdominal aortic aneurysm to determine whether the surveillance and reintervention framework established for elective repair remains safe and applicable. Methods We performed a single-institution retrospective cohort study of all patients undergoing emergency endovascular repair for ruptured abdominal aortic aneurysm between 2002 and 2022. To isolate long-term mechanical behavior, 30-day mortalities were excluded. The remaining survivors ( n = 28) were stratified by postoperative imaging into those with ( n = 8) and without ( n = 20) a Type II endoleak. Outcomes included all-cause mortality, aneurysm-related mortality, and sac dynamics (expansion ≥10 mm), assessed by Kaplan-Meier analysis and categorical testing. Results Over a median follow-up of 2.6 years (interquartile range, 0.5-4.8; range, 0.2-8.8 years), all-cause (log-rank P=.790) and aneurysm-related mortality (log-rank P=.826) did not differ between groups. The etiology of death, however, diverged. Deaths among patients without a Type II endoleak were driven by early physiological sequelae of the index rupture, and survivors showed durable sac stability (0% expansion). Sac expansion occurred exclusively among patients with a Type II endoleak (42.9% vs 0%; P=.017); no sac stabilized within the 5-to-10 mm range—every sac that reached 5 mm went on to exceed 10 mm. The expanding subgroup followed an aggressive course (100% all-cause and 66.7% aneurysm-related mortality) associated with late mechanical failure (late Type I endoleak, recurrent rupture). Conclusions Although long-term survival did not differ significantly, a Type II endoleak after endovascular repair of ruptured abdominal aortic aneurysm carries a markedly higher incidence of sac expansion and an associated vulnerability to late mechanical failure. Parallel survival trajectories indicate that the ruptured setting does not require a divergent management paradigm; strict adherence to established elective surveillance and reintervention guidelines is safe and effective, provided that any detected expansion prompts action rather than continued observation.