Outcomes of Management Strategies for Type Ia Endoleaks after Endovascular Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-analysis.

Abstract

This study aimed to systematically review and synthesise the available evidence on the management of type Ia endoleak (T1aEL) after endovascular aortic repair (EVAR). MEDLINE, Scopus, Web of Science, and the Cochrane Library. Studies reporting outcomes of interventions for T1aEL after EVAR were included if they presented cohorts of at least five patients. The certainty of evidence was assessed using the GRADE methodology, while risk of bias was evaluated at the study level using the ROBINS-I v2 tool. Sixty-three non-randomised studies were included, comprising 2 284 patients (89.0% male, 95% confidence interval [CI] 87.4 - 90.5%) with a weighted mean age of 76.2 years (95% CI 75.30 - 77.02 years). GRADE analysis determined the overall quality of evidence for all outcomes to be very low. The estimated mean interval between index EVAR and T1aEL correction was 47.3 months (95% CI 37.60 - 56.93 months). Overall estimated technical success and clinical success were 95.2% (95% CI 93.9 - 96.4%) and 91.9% (95% CI 90.0 - 93.8%), respectively. Of the 2 284 patients, 1 220 patients underwent fenestrated or branched EVAR (F/BEVAR) (technical success 94.4%, 95% CI 91.6 - 96.8%), 424 open conversion (technical success 94.7%, 95% CI 90.2 - 98.1%), 209 proximal extension (technical success 97.9%, 95% CI 93.9 - 100%), 149 chimney EVAR (technical success 94.1%, 95% CI 88.8 - 98.1%), 117 embolisation (technical success 95.4%, 95% CI 89.7 - 99.2%), 102 endostaples (technical success 76%, 95% CI 39.3 - 99.3%), and 63 physician modified endografts (technical success 97.8%, 95% CI 94.1 - 100%). Estimated overall early mortality was 3.5% (95% CI 2.7 - 4.3%). Endoleak resolution at follow up (mean 19.0 months, 95% CI 16.11 - 21.95 months) was maintained in 96.0% (95% CI 94.6 - 97.3) of patients. T1aEL treatment is feasible in selected cases, with apparently acceptable technical and clinical success rates. F/BEVAR has emerged as the most frequently adopted approach. Treatment selection should be individualised, taking into account anatomic characteristics, patient fitness, life expectancy, and endoleak specific features.