Type II Endoleak: An Ambiguous and Unpredictable Marker of Worse Outcome After EVAR

Objectives To analyze predictors and long-term consequence of type II endoleak in a large series of elective EVAR. Methods Baseline characteristics, operative and follow-up data of consecutive patients undergoing EVAR were prospectively collected. Patients who developed type II endoleak according to CT scan and those without were compared for baseline characteristic, mortality, reintervention, conversion and aneurysm growth after repair. Results 1412 consecutive patients (91.4% males; mean age, 72.9) underwent elective EVAR in 1997-2012 and were subsequently followed for a mean of 54 ± 42 months. 218 developed type II endoleak. Multivariate analysis failed to identify type II endoleak significant independent predictors with the exception of age (P = .026; OR, 1.023) and neck thrombus (P = .011; OR, .303). Rates of type II endoleak were comparable regardless the type of device but there was a tendency for lower rate with most recent generation devices. Freedom from aneurysm sac growth >5 mm (95.2% vs 42.4%; P < .001) reintervention (92.3% vs 49.6%; P < .001) or conversion (98.5% vs 80%; P < .001) at 120 months was higher in patients without type II endoleak. Fifty-two patients with type II endoleak underwent reintervention. At 60 months, rates of persisting type II endoleak were similar among patients with and without reinterventions (49.8% vs 45.6%). There were no significant difference in persisting aneurysm growth >5 mm in type II endoleak patients after reintervention and those who remained untreated (57.1% vs 42.6%). Cox regression identified type II endoleak as independent predictor of aneurysm growth along with age and cardiac disease. There were four aneurysm ruptures during follow-up in patients with type II endoleak. Late aneurysm related mortality at 120 months was 3.8% vs 2.1% for patients with and without type II endoleak. Conclusions Type II endoleak is a common marker of EVAR failure reflecting multiple meanings. Occurrence and consequences are challenging to be predicted and treatment with reinterventions often results in failure.