Endovascular repair of thoracoabdominal aneurysms requiring sealing above the renal arteries, with preservation of visceral vessels using fenestrated and/or branched devices (F/B-EVAR), has become a valid alternative to open surgery. However, endoleak remains a frequent complication and a potential driver of aneurysm sac growth. In this context, the study evaluated whether, in the absence of sac growth, a structured surveillance strategy with computed tomography angiography (CTA) could avoid unnecessary reinterventions.
Study characteristics
A single-center retrospective analysis was conducted at the Medical University of Vienna (Austria), including 230 consecutive patients treated between 2015 and 2024. Median age was 74 years, and 21% were women. All patients underwent a pre-discharge CTA. At this initial assessment, 75% presented some type of endoleak. Patients with type I or III endoleak, or mixed endoleak, without sac growth were followed at 6 months, whereas those with type II endoleak or no endoleak were followed at 12 months. Reintervention was indicated in the presence of sac growth >5 mm at 6 months or >10 mm at 12 months.
The primary endpoint was spontaneous resolution of the endoleak. Secondary endpoints included associated clinical and morphological factors, as well as changes in aneurysm sac volume.
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Endoleaks after F/B-EVAR: when CTA surveillance is a safe option
Among the 172 patients with endoleak at discharge, distribution was as follows: type I 3% (n=5), type II 34% (n=59), type III 19% (n=33), and mixed endoleak 44% (n=75). Type I endoleaks did not show spontaneous resolution. In contrast, type III endoleaks demonstrated a high resolution rate: 25% at 3 months, 39% at 6 months, 52% at 12 months, and 83% at 24 months, with no sac ruptures during follow-up. Mixed endoleaks showed a lower resolution rate (28% at 24 months), although the type II/III combination achieved a 50% resolution rate at 12 months.
Volumetric analysis identified a cutoff of 9.37 mL to define “small” and “large” endoleaks. Both groups showed similar resolution rates at 12 months (44% vs. 36%); however, at 24 months, small endoleaks resolved more frequently (72% vs. 48%). Overall, 19 patients experienced significant sac growth and were evaluated for reintervention. In multivariate analysis, three predictors were associated with a higher likelihood of spontaneous resolution: smaller maximum aortic diameter (OR 0.96; p=0.011), reduction in aneurysm sac size (OR 9.7; p<0.001), and a history of peripheral arterial disease (OR 3.6; p=0.007).
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Conclusions: structured CTA surveillance after complex EVAR
In conclusion, in patients undergoing F/B-EVAR with type III or mixed type II/III endoleak and no sac growth on pre-discharge CTA, a CTA-based surveillance strategy—rather than immediate reintervention—proved to be safe. An 83% spontaneous resolution rate of type III endoleaks at 24 months, absence of ruptures, and a limited need for reintervention (≈8%) were observed. These findings support a strictly protocolized conservative approach in carefully selected patients.
Original Title: CTA Surveillance for Conservative Endoleak Treatment following Complex Endovascular Aneurysm Repair.
Reference: Lukas Fuchs, Anna Sotir, Johannes Klopf, Daria Anokhina, Lina El-Kilany, Florian Wolf, Christoph Neumayer, Wolf Eilenberg. Journal of Vascular Surgery.
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