J ENDOVASC THER 2012;19:128–130-Letters to he Editors-Type II Endoleak: From Treatment of a Complication to Prevention (Chirurgia Vascolare-ULSS 15 Alta Padovana) (Vascular Surgery -ULSS 15 Alta Padovana)

1. ¤LETTERS TO THE EDITORS ¤
Type II Endoleak: From Treatment of a
Complication to Prevention
To the Editors:
Even at low flow, type II endoleak may prevent
thrombosis of the aneurysm sac and perpetu-
ate the risks of aneurysm expansion and
rupture after endovascular aneurysm repair
(EVAR).1
Accounting for ,40% of all endo-
leaks, type II leaks are typically of questionable
clinical significance, given that nearly half will
thrombose spontaneously.1
The best indicator
of hemodynamic significance of a type II
endoleak is an increase in the aneurysm sac,
which implies sustained systemic pressure
and a higher risk of rupture. If the sac is stable
or decreasing in size, the risk is likely to be less.
Thus, many clinicians assume a ‘‘wait and
see’’ approach with regular follow-up when
there is no expansion of the aneurysm sac.
Several treatment options are available for
the management of type II endoleak, but open
surgery is, in most cases, the only choice.1
Among the endovascular options, transarter-
ial embolization of the branch vessels with
coils, glue, or thrombin is the most typical.
This technique can be effective but requires
advanced endovascular skills, is time con-
suming, and is not possible in all patients
because of anatomical limitations. Further-
more, failure and recurrences have been
reported in up to 80% of cases.1–4
If an endoleak cannot be reached by a
transvascular route, translumbar emboliza-
tion using a combination of glue and coils
under computed tomography guidance can
be performed. This technique, first described
by Baum et al.,4
may be used as a primary
treatment or after failure of the transarterial
approach. A transabdominal approach with
ultrasound guidance has been proven feasible
as well. Laparoscopic retroperitoneal ligation
with clipping of the IMA or the lumbar arteries
is another option for treatment of a type II
endoleak.5,6
Transcaval embolization and en-
doscopic aneurysm sac fenestration are also
possiblilities.1
Nevertheless, most of these
techniques seldom solve this problem once
present, and surgery becomes inevitable.
We are of the opinion that prevention is a
better approach to this complication, and
several methods have been employed to this
end over the past 2 decades.7–10
Prophylactic
embolization of large patent inferior mesenteric
(IMA) and lumbar arteries before or during
endograft placement has been evaluated on
and off over the years,7,8
but many studies have
failed to show any benefit from this approach.11
Moreover, IMA embolization does not avoid
type II endoleak, which can develop in patients
with a chronically occluded IMA.
Natural history and our experience in the
treatment of type II endoleak led us to investi-
gate prevention as the best strategy in manag-
ing this complication.12–14
Intrasac ‘‘thrombiza-
tion’’ (fibrin glue injection with or without coil
insertion) performed during EVAR allowed us
to achieve a significant reduction in type II
endoleak.14
In a further analysis of our experi-
ence in .600 EVAR cases performed from
September 1999 to December 2010,14
we
analyzed 545 patients who had at least
12 months of follow-up (mean 29 months). Of
the 228 patients who underwent standard
EVAR, the incidence of type II endoleak was
1.97 per 100 person-months; in the 317 patients
who underwent EVAR + thrombization, the
incidence was 0.85 per 100 person-months.
Kaplan-Meier survival analysis documented a
clear difference between the groups even after
1 year of follow-up (p,0.0001 by the log-rank
test). Patients with sac thrombization were far
less likely to develop type II endoleak (hazard
ratio 0.20, 95% confidence interval 0.10 to 0.40).
The treatment of type II endoleak causing sac
enlargement is always difficult, dangerous, and
almost always ends with a surgical conversion.
In .10 years of experience, we have treated 10
type II endoleaks associated with sac enlarge-
ment: 9 in the first group and 1 in the EVAR +
thrombization group. Some patients had endo-
vascular attempts to treat the endoleak, but all
eventually underwent surgical conversion. Even
if EVAR plus preventive sac ‘‘thrombization’’
costs about 630 dollars more than EVAR alone,
128 J ENDOVASC THER
2012;19:128–130
ß 2012 by the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS Available at www.jevt.org

2. we believe that type II endoleak prevention
saves money and time because we do not have
to treat the complication, and we can use a less
stringent follow-up protocol.
Prevention is the best strategy to manage
type II endoleak, and new approaches to this
challenge will evolve.15
At present, intraoper-
ative intrasac thrombization with biomaterials
is a quick and safe technique, regardless of
the stent-graft used. In our experience, it is
effective in significantly reducing the inci-
dence of type II endoleak even in follow-up
beyond 1 year. Thus, it has the potential to
increase the durability of EVAR, lessen the
use of close follow-up, and avoid the need to
treat the complication in the long run.
Salvatore Ronsivalle, MD1
Francesca Faresin, MD1
Francesca Franz, MD1
Carlo Rettore, MD2
Mario Zanchetta, MD3
Armando Olivieri, MD4
1Department of Cardiovascular Disease,
Vascular and Endovascular Surgery,
and Angiology; 2
Department of Radiology;
3
Division of Cardiology;
4Department of
Prevention–Epidemiology Unit
Cittadella Hospital
Padua, Italy
vascolare_cit@ulss15.pd.it
The authors have no commercial, proprietary, or financial
interest in any products or companies described in this
correspondence.
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