Type II endoleaks
2014; Elsevier BV; Volume: 60; Issue: 5 Linguagem: Inglês
10.1016/j.jvs.2014.07.100
ISSN1097-6809
AutoresEfthymios D. Avgerinos, Rabih A. Chaer, Michel S. Makaroun,
Tópico(s)Aortic Disease and Treatment Approaches
ResumoType II endoleaks after endovascular aneurysm repair are the most common type of endoleak and generate the majority of secondary interventions. Their natural history is mostly benign, but they can occasionally lead to sac expansion and eventual rupture. Three-phase computed tomography angiography is the “gold standard” for diagnosis, but duplex ultrasound with or without contrast enhancement and magnetic resonance angiography offer an alternative for endoleak detection or surveillance. Whereas there are concerns as to whether sac expansion can be a dependable marker for risk of rupture, it is currently the best surrogate available and guides the indication for intervention. Obliteration of type II endoleaks can be challenging, and a variety of techniques, endovascular, open, and laparoscopic, have been proposed. The most common approaches are transarterial and translumbar embolization, and they are usually successful, provided the operator is experienced and persistent, targeting both the branches and the nidus of the endoleak. Recurrences and subsequent reinterventions should be anticipated, and on continuing sac expansion, repeated endovascular or open surgical and laparoscopic alternatives may be required. Type II endoleaks after endovascular aneurysm repair are the most common type of endoleak and generate the majority of secondary interventions. Their natural history is mostly benign, but they can occasionally lead to sac expansion and eventual rupture. Three-phase computed tomography angiography is the “gold standard” for diagnosis, but duplex ultrasound with or without contrast enhancement and magnetic resonance angiography offer an alternative for endoleak detection or surveillance. Whereas there are concerns as to whether sac expansion can be a dependable marker for risk of rupture, it is currently the best surrogate available and guides the indication for intervention. Obliteration of type II endoleaks can be challenging, and a variety of techniques, endovascular, open, and laparoscopic, have been proposed. The most common approaches are transarterial and translumbar embolization, and they are usually successful, provided the operator is experienced and persistent, targeting both the branches and the nidus of the endoleak. Recurrences and subsequent reinterventions should be anticipated, and on continuing sac expansion, repeated endovascular or open surgical and laparoscopic alternatives may be required. Endovascular aneurysm repair (EVAR) is currently widely accepted as the standard of care for infrarenal abdominal aortic aneurysm repair for patients with suitable anatomy.1Chaikof E.L. Brewster D.C. Dalman R.L. Makaroun M.S. Illig K.A. Sicard G.A. et al.The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines.J Vasc Surg. 2009; 50: S2-49Abstract Full Text Full Text PDF PubMed Scopus (563) Google Scholar, 2Moll F.L. Powell J.T. Fraedrich G. Verzini F. Haulon S. Waltham M. et al.Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery.Eur J Vasc Endovasc Surg. 2011; 41: S1-S58Abstract Full Text Full Text PDF PubMed Scopus (1128) Google Scholar, 3Stather P.W. Sidloff D. Dattani N. Choke E. Bown M.J. Sayers R.D. Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm.Br J Surg. 2013; 100: 863-872Crossref PubMed Scopus (258) Google Scholar, 4Wyss T.R. Brown L.C. Powell J.T. Greenhalgh R.M. Rate and predictability of graft rupture after endovascular and open abdominal aortic aneurysm repair: data from the EVAR trials.Ann Surg. 2010; 252: 805-812Crossref PubMed Scopus (6) Google Scholar, 5Dangas G. O'Connor D. Firwana B. Brar S. Ellozy S. Vouyouka A. et al.Open versus endovascular stent graft repair of abdominal aortic aneurysms: a meta-analysis of randomized trials.JACC Cardiovasc Interv. 2012; 5: 1071-1080Crossref PubMed Scopus (90) Google Scholar The need for serial surveillance and frequent reinterventions predominantly related to the anticipation or treatment of endoleaks accounts for its weaknesses and continues to limit its cost-effectiveness. Whereas there is little controversy in the management of type I and type III endoleaks, type II endoleaks have generated conflicting reports about their natural history, detection, and follow-up and the optimal timing and type of management. This review summarizes the accumulated evidence on type II endoleaks with particular focus on contemporary detection strategies, treatment criteria, and technical options (Table).TableSummary of evidence on type II endoleaksIncidence•8%-10% overall5Dangas G. O'Connor D. Firwana B. Brar S. Ellozy S. Vouyouka A. et al.Open versus endovascular stent graft repair of abdominal aortic aneurysms: a meta-analysis of randomized trials.JACC Cardiovasc Interv. 2012; 5: 1071-1080Crossref PubMed Scopus (90) Google Scholar, 10van Marrewijk C.J. Fransen G. Laheij R.J. Harris P.L. Buth J. Is a type II endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up.Eur J Vasc Endovasc Surg. 2004; 27: 128-137Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar, 12Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (185) Google Scholar, 13Drury D. Michaels J.A. Jones L. Ayiku L. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm.Br J Surg. 2005; 92: 937-946Crossref PubMed Scopus (179) Google Scholar•15% at 1-6 months after EVAR8Sheehan M.K. Ouriel K. Greenberg R. McCann R. Murphy M. Fillinger M. et al.Are type II endoleaks after endovascular aneurysm repair endograft dependent?.J Vasc Surg. 2006; 43: 657-661Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 13Drury D. Michaels J.A. Jones L. Ayiku L. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm.Br J Surg. 2005; 92: 937-946Crossref PubMed Scopus (179) Google Scholar• 6 months, higher rates of sac enlargement (up to 55%) should be anticipated.10van Marrewijk C.J. Fransen G. Laheij R.J. Harris P.L. Buth J. Is a type II endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up.Eur J Vasc Endovasc Surg. 2004; 27: 128-137Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar, 14Silverberg D. Baril D.T. Ellozy S.H. Carroccio A. Greyrose S.E. Lookstein R.A. et al.An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach.J Vasc Surg. 2006; 44: 453-459Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 17Jones J.E. Atkins M.D. Brewster D.C. Chung T.K. Kwolek C.J. LaMuraglia G.M. et al.Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.J Vasc Surg. 2007; 46: 1-8Abstract Full Text Full Text PDF PubMed Scopus (330) Google Scholar, 18Schlosser F.J. Gusberg R.J. Dardik A. Lin P.H. Verhagen H.J. Moll F.L. et al.Aneurysm rupture after EVAR: can the ultimate failure be predicted?.Eur J Vasc Endovasc Surg. 2009; 37: 15-22Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar•∼1% risk of rupture4Wyss T.R. Brown L.C. Powell J.T. Greenhalgh R.M. Rate and predictability of graft rupture after endovascular and open abdominal aortic aneurysm repair: data from the EVAR trials.Ann Surg. 2010; 252: 805-812Crossref PubMed Scopus (6) Google Scholar, 12Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (185) Google Scholar, 19Walker J. Tucker L.Y. Goodney P. Hua H. Okuhn S. Rhoades A. et al.Type II endoleak with or without intervention after endovascular aortic aneurysm repair (EVAR) does not change long term outcomes despite aneurysm sac growth.J Vasc Surg. 2014; 59: 5sAbstract Full Text Full Text PDF Google Scholar, 20van Marrewijk C.J. Buth J. Harris P.L. Norgren L. Nevelsteen A. Wyatt M.G. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience.J Vasc Surg. 2002; 35: 461-473Abstract Full Text Full Text PDF PubMed Scopus (434) Google Scholar•No evidence that sac enlargement is related to rupture4Wyss T.R. Brown L.C. Powell J.T. Greenhalgh R.M. Rate and predictability of graft rupture after endovascular and open abdominal aortic aneurysm repair: data from the EVAR trials.Ann Surg. 2010; 252: 805-812Crossref PubMed Scopus (6) Google Scholar, 12Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (185) Google Scholar, 19Walker J. Tucker L.Y. Goodney P. Hua H. Okuhn S. Rhoades A. et al.Type II endoleak with or without intervention after endovascular aortic aneurysm repair (EVAR) does not change long term outcomes despite aneurysm sac growth.J Vasc Surg. 2014; 59: 5sAbstract Full Text Full Text PDF Google Scholar, 20van Marrewijk C.J. Buth J. Harris P.L. Norgren L. Nevelsteen A. Wyatt M.G. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience.J Vasc Surg. 2002; 35: 461-473Abstract Full Text Full Text PDF PubMed Scopus (434) Google ScholarDetection•Three-phase CTA is the “gold standard.”•Contrast-enhanced ultrasound and magnetic resonance angiography may have accuracy equivalent to if not better than that of CTA. Yet, they are not widely available, and diagnosis is highly operator dependent.21Stavropoulos S.W. Charagundla S.R. Imaging techniques for detection and management of endoleaks after endovascular aortic aneurysm repair.Radiology. 2007; 243: 641-655Crossref PubMed Scopus (190) Google Scholar, 22Cantisani V. Ricci P. Grazhdani H. Napoli A. Fanelli F. Catalano C. et al.Prospective comparative analysis of colour-Doppler ultrasound, contrast-enhanced ultrasound, computed tomography and magnetic resonance in detecting endoleak after endovascular abdominal aortic aneurysm repair.Eur J Vasc Endovasc Surg. 2011; 41: 186-192Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar•DUS is the most cost-effective follow-up test and can be used for monitoring aneurysm sac growth. Type II endoleaks can be differentiated, but diagnosis is highly operator dependent.6Parent F.N. Meier G.H. Godziachvili V. LeSar C.J. Parker F.M. Carter K.A. et al.The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan.J Vasc Surg. 2002; 35: 474-481Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar, 22Cantisani V. Ricci P. Grazhdani H. Napoli A. Fanelli F. Catalano C. et al.Prospective comparative analysis of colour-Doppler ultrasound, contrast-enhanced ultrasound, computed tomography and magnetic resonance in detecting endoleak after endovascular abdominal aortic aneurysm repair.Eur J Vasc Endovasc Surg. 2011; 41: 186-192Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 24Chaer R.A. Gushchin A. Rhee R. Marone L. Cho J.S. Leers S. et al.Duplex ultrasound as the sole long-term surveillance method post-endovascular aneurysm repair: a safe alternative for stable aneurysms.J Vasc Surg. 2009; 49 (discussion: 849-50): 845-849Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 25Harrison G.J. Oshin O.A. Vallabhaneni S.R. Brennan J.A. Fisher R.K. McWilliams R.G. Surveillance after EVAR based on duplex ultrasound and abdominal radiography.Eur J Vasc Endovasc Surg. 2011; 42: 187-192Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 26Go M.R. Barbato J.E. Rhee R.Y. Makaroun M.S. What is the clinical utility of a 6-month computed tomography in the follow-up of endovascular aneurysm repair patients?.J Vasc Surg. 2008; 47 (discussion: 1186-7): 1181-1186Abstract Full Text Full Text PDF PubMed Scopus (49) Google ScholarDecision to treat•Lack of robust evidence1Chaikof E.L. Brewster D.C. Dalman R.L. Makaroun M.S. Illig K.A. Sicard G.A. et al.The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines.J Vasc Surg. 2009; 50: S2-49Abstract Full Text Full Text PDF PubMed Scopus (563) Google Scholar, 2Moll F.L. Powell J.T. Fraedrich G. Verzini F. Haulon S. Waltham M. et al.Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery.Eur J Vasc Endovasc Surg. 2011; 41: S1-S58Abstract Full Text Full Text PDF PubMed Scopus (1128) Google Scholar, 12Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (185) Google Scholar•Intervention is warranted only on sac enlargement >5 mm but not for endoleak persistence.1Chaikof E.L. Brewster D.C. Dalman R.L. Makaroun M.S. Illig K.A. Sicard G.A. et al.The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines.J Vasc Surg. 2009; 50: S2-49Abstract Full Text Full Text PDF PubMed Scopus (563) Google Scholar, 2Moll F.L. Powell J.T. Fraedrich G. Verzini F. Haulon S. Waltham M. et al.Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery.Eur J Vasc Endovasc Surg. 2011; 41: S1-S58Abstract Full Text Full Text PDF PubMed Scopus (1128) Google ScholarTreatment•Endovascular techniques are preferred as minimally invasive.•Percutaneous transarterial embolization is the most common intervention. Average success rate is 63% (range, 15%-89%).12Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (185) Google Scholar•Translumbar embolization is a reasonable alternative, particularly when there is no transarterial access. Average success rate is 81% (range, 67%-100%).12Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (185) Google Scholar•Evidence on ventral or transcaval sac puncture is insufficient.16Uthoff H. Katzen B.T. Gandhi R. Pena C.S. Benenati J.F. Geisbusch P. Direct percutaneous sac injection for postoperative endoleak treatment after endovascular aortic aneurysm repair.J Vasc Surg. 2012; 56: 965-972Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 27Sheehan M.K. Barbato J. Compton C.N. Zajko A. Rhee R. Makaroun M.S. Effectiveness of coiling in the treatment of endoleaks after endovascular repair.J Vasc Surg. 2004; 40: 430-434Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar•Embolization should target the nidus and the feeder branches of the endoleak.12Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (185) Google Scholar, 26Go M.R. Barbato J.E. Rhee R.Y. Makaroun M.S. What is the clinical utility of a 6-month computed tomography in the follow-up of endovascular aneurysm repair patients?.J Vasc Surg. 2008; 47 (discussion: 1186-7): 1181-1186Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 28Baum R.A. Carpenter J.P. Golden M.A. Velasquez O.C. Clark T.W. Stavropoulos W.S. et al.Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.J Vasc Surg. 2002; 35: 23-29Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar•Microcoils are mainly used, but glue, thrombin, and Onyx can also be delivered, with no proven superiority of one agent over the other.•Operator should be persistent and cautious to potentially uncover a type I or type III endoleak.19Walker J. Tucker L.Y. Goodney P. Hua H. Okuhn S. Rhoades A. et al.Type II endoleak with or without intervention after endovascular aortic aneurysm repair (EVAR) does not change long term outcomes despite aneurysm sac growth.J Vasc Surg. 2014; 59: 5sAbstract Full Text Full Text PDF Google Scholar, 29Rial R. Serrano F.J. Vega M. Rodriguez R. Martin A. Mendez J. et al.Treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysms: translumbar puncture and injection of thrombin into the aneurysm sac.Eur J Vasc Endovasc Surg. 2004; 27: 333-335Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 30Massis K. Carson III, W.G. Rozas A. Patel V. Zwiebel B. Treatment of type II endoleaks with ethylene-vinyl-alcohol copolymer (Onyx).Vasc Endovasc Surg. 2012; 46: 251-257Crossref PubMed Scopus (44) Google Scholar•If the endoleak persists and the sac continues to grow after “technically” successful embolizations or when embolization is impossible, more invasive approaches are required.•Laparotomy or laparoscopy with ligation of the feeding side branches, suturing of the side branch ostia within the aneurysmal sac, and conversion to open repair are all feasible alternatives that carry higher complexity, morbidity, and mortality.CTA, Computed tomography angiography; DUS, duplex ultrasound; EVAR, endovascular aneurysm repair. Open table in a new tab CTA, Computed tomography angiography; DUS, duplex ultrasound; EVAR, endovascular aneurysm repair. Type II endoleaks are “procedure related” as a result of patent lumbar arteries or inferior mesenteric artery branches and may involve various flow patterns.6Parent F.N. Meier G.H. Godziachvili V. LeSar C.J. Parker F.M. Carter K.A. et al.The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan.J Vasc Surg. 2002; 35: 474-481Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar They represent the most frequent type of endoleak, and the incidence has been correlated, although not uniformly, with the number and size of patent branches before exclusion.7Peterson B.G. Matsumura J.S. Brewster D.C. Makaroun M.S. Five-year report of a multicenter controlled clinical trial of open versus endovascular treatment of abdominal aortic aneurysms.J Vasc Surg. 2007; 45: 885-890Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 8Sheehan M.K. Ouriel K. Greenberg R. McCann R. Murphy M. Fillinger M. et al.Are type II endoleaks after endovascular aneurysm repair endograft dependent?.J Vasc Surg. 2006; 43: 657-661Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 9Makaroun M. Zajko A. Sugimoto H. Eskandari M. Webster M. Fate of endoleaks after endoluminal repair of abdominal aortic aneurysms with the EVT device.Eur J Vasc Endovasc Surg. 1999; 18: 185-190Abstract Full Text PDF PubMed Scopus (87) Google Scholar, 10van Marrewijk C.J. Fransen G. Laheij R.J. Harris P.L. Buth J. Is a type II endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up.Eur J Vasc Endovasc Surg. 2004; 27: 128-137Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar Earlier studies showed possible endograft dependence, but this does not appear to be the case in later studies with longer follow-up.8Sheehan M.K. Ouriel K. Greenberg R. McCann R. Murphy M. Fillinger M. et al.Are type II endoleaks after endovascular aneurysm repair endograft dependent?.J Vasc Surg. 2006; 43: 657-661Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 11Broker H.S. Foteh K.I. Murphy E.H. Davis C.M. Clagett G.P. Modrall J.G. et al.Device-specific aneurysm sac morphology after endovascular aneurysm repair: evaluation of contemporary graft materials.J Vasc Surg. 2008; 47 (discussion: 707): 702-706Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The largest published series comes from the EUROSTAR (European Collaborators on Stent/graft Techniques for aortic Aneurysm Repair) registry (3595 patients), reporting a 9% rate of type II endoleak diagnosed any time during follow-up,10van Marrewijk C.J. Fransen G. Laheij R.J. Harris P.L. Buth J. Is a type II endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up.Eur J Vasc Endovasc Surg. 2004; 27: 128-137Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar similar to the 8% to 10% rates reported in large systematic reviews and meta-analyses.5Dangas G. O'Connor D. Firwana B. Brar S. Ellozy S. Vouyouka A. et al.Open versus endovascular stent graft repair of abdominal aortic aneurysms: a meta-analysis of randomized trials.JACC Cardiovasc Interv. 2012; 5: 1071-1080Crossref PubMed Scopus (90) Google Scholar, 12Sidloff D.A. Stather P.W. Choke E. Bown M.J. Sayers R.D. Type II endoleak after endovascular aneurysm repair.Br J Surg. 2013; 100: 1262-1270Crossref PubMed Scopus (185) Google Scholar, 13Drury D. Michaels J.A. Jones L. Ayiku L. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm.Br J Surg. 2005; 92: 937-946Crossref PubMed Scopus (179) Google Scholar The rate is generally higher at 1 to 6 months and occurs in around 15% of patients, and although some type II endoleaks may be identified at a later date, the prevalence gradually decreases to 5 mm. The rate of sac enlargement gets even higher, up to 55%, for endoleaks that persist for >6 months.10van Marrewijk C.J. Fransen G. Laheij R.J. Harris P.L. Buth J. Is a type II endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up.Eur J Vasc Endovasc Surg. 2004; 27: 128-137Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar, 14Silverberg D. Baril D.T. Ellozy S.H. Carroccio A. Greyrose S.E. Lookstein R.A. et al.An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach.J Vasc Surg. 2006; 44: 453-459Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 17Jones J.E. Atkins M.D. Brewster D.C. Chung T.K. Kwolek C.J. LaMuraglia G.M. et al.Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.J Vasc Surg. 2007; 46: 1-8Abstract Full Text Full Text PDF PubMed Scopus (330) Google Scholar, 18Schlosser F.J. Gusberg R.J. Dardik A. Lin P.H. Verhagen H.J. Moll F.L. et al.Aneurysm rupture after EVAR: can the ultimate failure be predicted?.Eur J Vasc Endovasc Surg. 2009; 37: 15-22Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar Whereas there is no clear evidence that sac expansion in this setting is a surrogate for future aneurysm rupture, aneurysm rupture does occur, although rarely, in patients with type II endoleaks.4Wyss T.R. Brown L.C. Powell J.T. Greenhalgh R.M. Rate and predictability of graft rupture after endovascular and open abdominal aortic aneurysm repair: data from the EVAR trials.Ann Surg. 2010; 252: 805-812Crossref PubMed Scopus (6) Google Scholar, 19Walker J. Tucker L.Y. Goodney P. Hua H. Okuhn S. Rhoades A. et al.Type II endoleak with or without intervention after endovascular aortic aneurysm repair (EVAR) does not change long term outcomes despite aneurysm sac growth.J Vasc Surg. 2014; 59: 5sAbstract Full Text Full Text PDF Google Scholar Data from the EUROSTAR registry on 2463 patients suggested a cumulative 2-year incidence of rupture after type II endoleak of 1.8% (one of 55 patients)20van Marrewijk C.J. Buth J. Harris P.L. Norgren L. Nevelsteen A. Wyatt M.G. Significance of endoleaks after endovascular repair of abdominal ao
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