1. There are different types of endoleaks that can occur after EVAR, with Types I and III considered the most serious due to their risk of rupture if not treated. 2. Type II endoleaks are more common but often have a benign natural history, with many resolving spontaneously. Treatment is only recommended if the aneurysm sac enlarges. 3. Endovascular techniques can be used to treat Type I, II, and III endoleaks via extensions, coils, glue, or onyx, with the goal of occluding the source of blood flow into the sac. Transarterial, translumbar, and transcaval approaches may be necessary depending on anatomy.

1. Management of Endoleaks after EVAR
Michel Makaroun MD
Co-Director UPMC Heart and Vascular Institute
Professor and Chief, Division of Vascular Surgery
University of Pittsburgh School of Medicine

2. Disclosures
Consultant:
WL Gore, Cordis, Medtronic
Research Grants:
WL Gore, Cook, Cordis
Medtronic, Boston Scientific, Abbott
Bolton, Lombard, Trivascular

3. Type I
Attachment leak
Type II
Branch flow
Type III
Defect in graft or
modular disconnection
Type IV
Fabric porosity
The Different Types of Endoleaks

4. There is almost uniform consensus about
Type I and III Endoleaks
 They are serious and associated with a
significant risk of rupture!
 Should be treated whenever feasible:
either with
 Endovascular Salvage or
 Open Conversion

5. 6 Ruptures All from Type I or Type III

6. TYPE I + III
J Vasc Surg 2002;35:461-73

7. Type I Endoleaks

8. World Review of Ruptures after EVAR
55% (129/235) of All Ruptures
are due to Type I endoleaks
38 of the ruptures in the first 30 days

9. Intrasac Pressure Measurements
Before Exclusion
Mean Pressure: 75 mmHg
After EVAR with Type I
Mean Pressure: 111 mmHgBefore Implantation Type I endoleak

10.  Earliest EVAR Tube Experience
 Parodi first 50 patients (1995)
 5 Type I endoleaks (10%) : 3 proximal 2 distal
 4 died by 8 months, one from Rupture @2 months
20% Mortality from Rupture 1st
year !

11.  Earliest EVAR Bifurcated Experience
 Chuter first 41 patients (1996)
 9 Type I endoleaks (22%)
 2 Type I died within 3 days from rupture
22% Mortality from Rupture!

12. Early Experience proved Type I Endoleaks to be serious.
ALL Type I Endoleaks have since been treated when feasible
at original procedure or when discovered!!
1. Incidence has decreased significantly
2. Very few type I endoleaks are monitored conservatively
 Small endoleaks missed at completion angiography
 Endoleaks difficult to manage by endovascular means
in sick patients with limited life expectancy

13. Endovascular Rx of Type I Endoleaks
 Extensions with Stent Grafts
 High pressure balloons
 Increase Radial Force by Palmaz Stents
 Endostapling
Extension Simple and effective but can be limited by
1. Renals close to the proximal end
2. Essential internal iliac artery
In those situations
Coiling of the track may work
Or Coverage of the Renals with chimneys
Rarely Open Conversion is required
Higher Mortality and morbidity

14. Procedural Type I Endoleak Treated by Ballooning
Pre deployment Type I Endoleak Ballooning
No more endoleak

15. Procedural Type I Endoleak Treated by Extension
Pre deployment Type I Endoleak Extension
No more endoleak

16. Procedural Type I Endoleak Treated with Palmaz
Type I Endoleak Palmaz Stent No Endoleak

17. Procedural Type I Endoleak Treated by Endostaples
Courtesy of Jim Joye DO

18. Late Type I Endoleaks
 Can be due to Migration
 Aneurysmal degeneration of neck
 Enlargement of Iliac arteries
 Angulation

19. Treated with New Endograft inside first one
Endovascular Rx of Proximal Type I Endoleak
after Proximal Migration

20. Endovascular Rx of Distal Type I
from Iliac Degeneration
7 years post Ancure:
Distal Type I Endoleak
Right Limb
Endoleak
Excluder
14.5 x 7cm
Extension
No more
Endoleaks
Treated by Extension

21. Endovascular Rx of Proximal Type I Endoleak
after Proximal Migration
3 years post AneuRx:
Migration and Proximal
Type I
No More
Endoleaks
Treated by Extension and Palmaz Stent

22. Endovascular Rx of Proximal Type I Endoleak
after Proximal Migration
Treated by Extension and Left renal stent
Type I
Old Type II
coiled
NO Type I
No Room
To extend

23. Endovascular Rx of Proximal Type I Endoleak
with renal coverage and chimneys
Aneurysm
neck wall
Poor deployment and Type I Treated with suprarenal
Extension and 2
Failed
Extension
Palmaz
Staples

24. Coiling of Distal Type I
6 months post Tube Ancure
Distal Type I
Graft
Endoleak
Coils
1 Month Post Coiling 5.8 cm

25. Coiling of Distal Type I
1 year post coiling 4.6 cm 2 years post coiling 3.4 cm
5 year post coiling 2.8 cm4 year post coiling 2.8 cm

26. Type I
Open Conversion
Does not always require complete Explantation
Operative Mortality: 5-10%
High Morbididty
Conversion To Open Repair

27. Type III Endoleaks

28. Fabric Tear and Type III Endoleak
Fabric Tear from Wall stent in Ancure Rx with Excluder Limb
6 years after Implantation

29. Limb Disconnection and Type III endoleak
Rt Limb Disconnection in a Lifepath Rx with Excluder Limb
6 years after Implantation

30. How about Type II Endoleaks?
The opinions here are much more divided !

31. The Majority of Endoleaks are Type II
0
20
40
60
80
100
None Type I Type II Type III Type IV Type
Indet
%subjectsevaluated
12 Mos
24 Mos
36 Mos
48 Mos
60 Mos
Excluder Regulatory Trial: 5 year Chart

32. 12 Mos
Type II Total % Type II Total % Type II Total %
Talent 10 159 6.2%* 1 118 0.80% 0 113 0.00%
Lifepath 4 57 7.00%
Excluder 13 86 15.10% 8 55 14.50% 5 36 13.90%
Zenith 19 124 15.30% 3 43 7.00%
AneuRx 34 327 10.40% 29 210 13.80% 13 92 14.10%
Ancure 27 295 9.20% 15 213 7.00% 2 121 1.60%
Total 107 1048 10.20% 56 639 8.80% 20 362 5.50%
24 Mos 36 Mos
 Occurs with all Grafts in 14% (10-20%) of patients
 Prevalence decreases to 5-10% between 1-3 years
Sheehan MK, Makaroun MS et al J Vasc Surg 2006;43:657-61
Incidence Similar for ALL Endografts

33. Diagnosis of Type II Endoleaks
CT and Duplex agree in many cases on Endoleak.
Source of Endoleak ???

34. Diagnosis of Type II Endoleaks

35.  Source can be difficult to determine
 Some endoleaks are very complex
90 x 91 mm AAA
MB Nov 2003
MB Dec 2003
Type I Endoleak ??
Or is it IMA Type II ??
CT Diagnosis of Type II Endoleaks

36. SMA Injection
Large Patent IMA
Type II IMA Endoleak

37. MB February 2004
5 Fr Glide cath
Renegade
Microcath
Transcend
.014 wire

38. 1. WHEN TO TREAT?
The answer has changed steadily over the years
gradually favoring a more conservative approach
The current recommendation:
 Rx confirmed Type II Endoleaks ONLY when
associated with AAA sac Enlargement !
Also eliminates many unnecessary re-interventions

39. Evidence suggests that Type II endoleaks
have a relatively Benign Natural History !
0
10
20
30
40
50
60
70
80
90
OP D/C 3m 6m 12m 24m 36m
Excluded
Endoleaks
No Interventions until 6 Months
2/3 resolve spontaneously
by 6 months
Makaroun et al Eur J Vasc Endovasc Surg 1999;18:185-90
UPMC 1999

40. Spontaneous resolution can occur Late
Year 1. May 2003
Type II Endoleak
Year 2. May 2004
Type II Endoleak
Year 3. May 2005
No Endoleak
Late Spontaneous Resolution (3 Years)

41. Persistent
Type II Endoleak
Lumbars
September 2006
+ AAA can shrink despite Type II Endoleak
September 2005
53 x 55 mm
September 2006
43 x 45 mm
10 mm Decrease

42.  486 Patients with 90 Type II Endoleaks (18.5%)
 61% sealed spontaneously in 6 months
 Only 6% experienced enlargement > 5mm
J Vasc Surg 2004;39:306-13

43.  965 Patients with 154 Type II Endoleaks (16%)
 75% seal spontaneously in 5 years (KM analysis)
 Only 8.4% experienced enlargement > 5mm
J Vasc Surg 2006;44:453-59

44. So Should we Ignore Type II Endoleaks?
Probably not!

45.  Review of 270 Aneurysm Ruptures after EVAR
 Endoleaks the cause of rupture in 160 patients
 Type I or III in 114 Patients
 Type II in 23 Patients
Eur J Vasc Endovasc Surg 2009;37:15-22

46. Type II Endoleaks
 Usually run a benign course
 But can rarely result in rupture
 Should ONLY be treated when associated with
AAA enlargement!
Caveat: Increasing Sac Size is an unproven surrogate
for the potential of future rupture but quite likely

47. 2. How to do it?
There is no consensus as to the best way to treat
Type II Endoleaks, as they can be very different
from each other and can be very complex to treat.

48. Approaches to Type II Endoleaks
 Observation
 Laparoscopic clipping of branches
 Open Surgical Conversion
Partial or Complete
 Endovascular Approaches !!

49. Endovascular Rx of Type II Endoleaks
Multiple Branch Vessels involved
 IMA
 Multiple sets of Lumbars
 Other branches
 Large Nidus
Diagnosis is usually suspected by
Duplex or CT but has to be
confirmed at angiography!
Principle of Endo RX
 Obliterate the feeding vessels
and if possible the nidus
Three Different Approaches
 Trans-Arterial catheterization:
More technically demanding but
potentially more effective
 Translumbar puncture
 Transcaval direct access
Rx Nidus. Difficult to get vessels
Occluding Agents
 Glue
 Onyx
 Thrombin
 Coils

50. Onyx and Glue are liquid agents that help fill
nidus but very expensive and complicate FU
ONYX
18 m later size increased from 9 to 14 cm
and presented with a leaking AAA

51. Onyx and Glue are liquid agents that help fill
nidus but very expensive and complicate FU
Type III
Disconnection
Type IB
Endoleak
Unrecognized
Type II
Endoleak
Poorly coiled

52. 2. How I do it
Technical Notes
 Trans-arterial Coaxial System
 Micro-catheters
 Coils
 Can deliver very long coils if needed (Interlocks)
 Use Saline flush for short ones instead of coil pushers
 Make sure it is occluded
 Proximal lumbars (L1-L3) near impossible to reach

53. Int Iliac coils
6 Fr Sheath in Internal Iliac
5 Fr angled Catheter
Microcatheter

54. Lumbar Endoleak
Coils at
origin of Lumbar

55. Lumbar Endoleak Coils in Lumbar
One month later
Treatment of Type II Endoleaks

56. Coiling of Type II IMA Endoleak
IMA endoleak treated by coiling

57. Type II Endoleaks Can be Complex: Case AH
June 07: Lumbar
Type II endoleak
Microcatheter
Access
Lumbars Coiled
No endoleak

58. AH Oct 07: Endoleak still present/ AAA larger
Oct 07
Persistent
Endoleak
More
Feeders
Renegade
Micro
Catheter
Access to
AAA Sac
Complex Endoleak
Nidus and
Branches
Coiled
 Some endoleaks are complex and
require multiple interventions

59. Trans-Arterial Access Not Always Available
OW March 2012
Persistent
Endoleak
67x70 mm
Type II Endoleak
No Transarterial Access Right
No Transarterial Access left

60. Trans-Lumbar Approach Reasonable Alternative
OW March 2012
 Patient prone
 Shiba needle/ .018 wire
 Puncture endoleak
 Exchange for Stiff wire
 6 Fr 30 cm sheath
 Catheter
 Eliminate Nidus

61. Trans-Lumbar Approach Reasonable Alternative
OW March 2012
6 Fr Sheath
5 Fr angled Catheter
Microcatheter

62. Trans-Caval Approach Useful in Some Patients
 Patient Supine
 Trans-Caval approach
with a Rosch-Uchida
catheter
 Angiogram
 Direct embolization of
Nidus and branches
 Removal of catheter
and completion
cavogram

63. 3. Does it Work?
A qualified YES!
 Of course conversions (both partial and complete) do
work but associated morbidity is high
 Endovascular interventions are tedious and will work
in most, if operator is experienced and persistent

64. 3. Does it Work?
Unfortunately, Very little long term data exists!
It is easy to make claims of effectiveness since:
a) Many interventions were carried too early when
most endoleaks would have resolved spontaneously
b) Many techniques obstruct future imaging
c) No clear endpoint of effectiveness: Size of AAA

65.  UPMC experience 1995- 2003
 All Trans-Arterial coiling
 Endoleaks only treated if persistent > 6 months
 Success: No leaks and stable or shrinking AAA sac
 FU: Mean 18 months
J Vasc Surg 2004;40:430-4

66. Results of Coiling
 28 patients
 Follow-up 1-60mos
 Clinical Success (82%)
 15/19 (79%) Type II
 8/9 (89%) Type I
 Procedural Morbidity 0%
 Procedural Mortality 0%

67. Type II Endoleaks: Results of Coiling
 19 patients
 21 attempts
 2 patients required more
than one intervention
 Can be very complex
 15 successful
 1 IMA
 7 pure lumbar
 7 combined

68. 3 Lumbar Coils
Two years later
Two interventions later
Coils Not Occlusive
Multiple
Coils added
Till Occlusion

69. Several sources coexist in some complex cases
Type II
Lumbar
1 Year Year 2
Type I
Distal
Year 3
Type II
IMA

70.  Endovascular techniques can be used safely and
effectively to Treat Endoleaks after EVAR
 Type I and Type III should almost always be treated
when discovered
 Treatment of Type II should be reserved to patients
with sac enlargement
 Open Conversions may be necessary but carry a
higher morbidity and mortality
Summary