More proximal lumbar source of type II endoleak is associated with worse outcomes after infrarenal endovascular aneurysm repair.

Abstract

Type II endoleak (T2EL) after infrarenal endovascular aneurysm repair (EVAR) is often clinically insignificant, but can lead to aneurysm sac growth and rupture. Anatomical factors such as inferior mesenteric artery (IMA) size and lumbar artery patency have been established as risk factors for T2ELs, but the specific level of T2EL has yet to be investigated. We hypothesized that T2ELs involving more proximal lumbar vessels pose a greater risk of rupture and conversion to open repair compared with more distal lumbar T2ELs. We performed a retrospective chart review of patients who underwent EVAR for infrarenal abdominal aortic aneurysm at our institution from 2000 to 2023 and developed a T2EL. Inclusion criteria were age >18 years and follow-up through ≥1 year. Exclusion criteria included noninfrarenal abdominal aortic aneurysm and aneurysms repaired by means other than infrarenal EVAR. Cohorts were created based on the level of the T2EL, with a T2EL from L1 or L2 being a proximal T2EL and a T2EL from L3 to L5 being a distal T2EL. Rates of rupture or conversion to open repair were assessed in each group. We assessed demographic, medical history, and preoperative imaging variables between both groups. During the study period, there were 2662 aneurysm repairs performed, including 325 infrarenal EVAR procedures with confirmed T2ELs. Of the patients undergoing infrarenal EVAR, 257 met the inclusion criteria for this study. There were 42 proximal T2ELs and 215 distal T2ELs. There were 17 ruptures or open repairs in the cohort, including 5 confirmed ruptures and 12 open repairs. There were 6 ruptures or open repairs (14.2%) in the proximal endoleak cohort and 11 (5.1%) in the distal endoleak cohort (P < .05). IMA involvement in T2EL was not associated with a change in these rates in either group. T2ELs from the proximal lumbar arteries (L1-L2) are associated with a greater risk of aneurysm rupture or need for conversion to open repair compared with a distal T2EL. IMA involvement in T2EL was not associated with worse outcomes. Patients with an enlarging aneurysm sac diameter with a proximal T2EL should be offered more frequent surveillance and consideration should be given to open repair in medically fit individuals.