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Vascular and/or Interventional Radiology

E2836. Endoleaks: Identification on Cross-Sectional Imaging and Current Management Options

Panta O,  Thamtorawat S,  Rojwatcharapibarn S,  Nadarajan C. Siriraj Hospital, Bangkok Noi, Thailand

Address correspondence to O. Panta (bijupanta@yahoo.com)

Background Information: Endovascular aneurysm repair (EVAR) has now become the preferred method of aneurysm repair in patients with favorable anatomy. Endoleak is persistent flow into the aneurysmal sac after EVAR and is the commonest and serious complication of EVAR. The incidence of endoleak varies widely among studies ranging from 10% to 50%. Approach to treatment of endoleak may be endovascular, surgical, or combined and are dictated by the type of endoleak.

Educational Goals/Teaching Points: The goal of this presentation is to review the types of endoleak; their identification and diagnosis on cross-sectional imaging and digital subtraction angiography (DSA); endovascular, percutaneous, and surgical management; and strategies, challenges, and complications of treatment with case examples.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: Endoleaks are classified into 4 types based on their inflow into the aneurysmal sac; inflow from proximal or distal end of graft (type I), branch vessel (type II), graft material tear (type III) or porosity of the graft (type IV). Type I and III endoleaks have direct shunt between the aneurysm and the systemic circulation with high pressure and have high risk of aneurysm rupture and thus are treated aggressively while type II has a indolent course and the treatment is debatable. However treatment is warranted in type II endoleaks associated with sac enlargement. Type I endoleak may be treated with balloon aortoplasty alone or may require extension of the endograft, however in difficult anatomy with insufficient space between endograft and renal arteries, embolization of type I endoleaks has also been described. Type II endoleaks result due to back flow from branch vessels, inferior mesenteric artery, lumbar arteries that are occluded by the endograft. Type II endoleak behaves like a pseudoaneurysm or an AV malformation depending upon single or multiple feeding vessels and the management strategy is feeder occlusion or the nidus occlusion respectively. Type III endoleak are due to graft tear and are treated by insertion of endograft patch. Type IV endoleak are extremely rare now a days due to advancement of graft technologies.

Conclusion: With increasing number of EVAR performed and increasing follow-up imaging after EVAR, it is imperative for diagnostic radiologist to identify and classify accurately the type of endoleak on cross-sectional imaging technique and advocate the interventional radiological technique or surgical management for the treatment of these endoleaks.