Type II endoleak after endovascular abdominal aortic aneurysm repair: A conservative approach with selective intervention is safe and cost-effective

Objectives: The conservative versus therapeutic approach to type II endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) has been controversial. The purpose of this study was to evaluate the safety and cost-effectiveness of the conservative approach of embolizing type II endoleak only when persistent for more than 6 months and associated with aneurysm sac growth of 5 mm or more. Methods: Data for 486 consecutive patients who underwent EVAR were analyzed for incidence and outcome of type II endoleaks. Spiral computed tomography (CT) scans were reviewed, and patient outcome was evaluated at either office visit or telephone contact. Patients with new or late-appearing type II endoleak were evaluated with spiral CT at 6-month intervals to evaluate both persistence of the endoleak and size of the aneurysm sac. Persistent (≥6 months) type II endoleak and aneurysm sac growth of 5 mm or greater were treated with either translumbar glue or coil embolization of the lumbar source, or transarterial coil embolization of the inferior mesenteric artery. Results: Type II endoleaks were detected in 90 (18.5%) patients. With a mean follow-up of 21.7 ± 16 months, only 35 (7.2%) patients had type II endoleak that persisted for 6 months or longer. Aneurysm sac enlargement was noted in 5 patients, representing 1% of the total series. All 5 patients underwent successful translumbar sac embolization (n = 4) or transarterial inferior mesenteric artery embolization (n = 4) at a mean follow-up of 18.2 ± 8.0 month, with no recurrence or aneurysm sac growth. No patient with treated or untreated type II endoleak has had rupture of the aneurysm. The mean global cost for treatment of persistent type II endoleak associated with aneurysm sac growth was $6695.50 (hospital cost plus physician reimbursement. Treatment in the 30 patients with persistent type II endoleak but no aneurysm sac growth would have represented an additional cost of $200,000 or more. The presence or absence of a type II endoleak did not affect survival. (78% vs 73%) at 48 months. Conclusions: Selective intervention to treat type II endoleak that persists for 6 months and is associated with aneurysm enlargement seems to be both sale and cost-effective. Longer follow-up will determine whether this conservative approach to management of type II endoleak is the standard of care.