Endoleaks remain one of the leading causes of reintervention after endovascular repair of complex aortic aneurysms using fenestrated and/or branched endografts (F/B-EVAR). Traditionally, type I and type III endoleaks have been considered indications for early correction due to their association with persistent pressurization of the aneurysm sac and an increased risk of rupture. However, recent evidence suggests that some endoleaks may resolve spontaneously without increasing this risk. In this context, the present study evaluated the spontaneous resolution of endoleaks and associated factors in patients undergoing F/B-EVAR managed with a conservative strategy based on surveillance with computed tomography angiography (CTA).
A single-center retrospective study was conducted at the Division of Vascular Surgery of the Medical University of Vienna (Vienna, Austria), including 230 consecutive patients treated between January 2015 and June 2024 for complex aortic aneurysms, comprising juxtarenal, pararenal, paravisceral abdominal, and thoracoabdominal aneurysms. The median age was 74 ± 7 years, with a predominance of men (79%). On CTA performed prior to hospital discharge, 75% (n = 172) of patients presented some type of endoleak (type I, II, III, and mixed combinations).
All patients were followed using a standardized CTA protocol: those with type I and/or III endoleaks, or mixed endoleaks without sac enlargement, underwent tomographic follow-up at 6 months, whereas patients with isolated type II endoleaks or no endoleak were evaluated at 12 months. Endoleak resolution was defined as complete disappearance on CTA without the need for reintervention. Secondary intervention was indicated only in cases of aneurysm sac growth greater than 5 mm at 6 months or greater than 10 mm at 12 months.
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The primary endpoint was spontaneous resolution of the endoleak without the need for reintervention during follow-up. Secondary endpoints included identification of clinical, procedural, and morphological factors associated with spontaneous resolution, as well as aneurysm sac evolution.
During follow-up, type I endoleaks did not show spontaneous resolution. In contrast, type III endoleaks demonstrated a high rate of spontaneous closure, reaching 83% at 24 months, with most cases occurring within the first 12 months. Mixed endoleaks exhibited a significantly lower resolution rate (28% at 24 months; p < 0.001); however, the combined type II/III subtype showed a more favorable course, with spontaneous resolution in 50% of cases at 12 months.
No aneurysm ruptures were recorded throughout the follow-up period. When analyzing endoleak volume using a cutoff value of 9.37 mL, smaller and larger endoleaks showed comparable resolution rates up to 12 months (44% vs. 36%). Beyond this period, smaller-volume endoleaks demonstrated a significantly higher probability of spontaneous resolution (p = 0.039).
In multivariate analysis, a smaller maximum aortic diameter was independently associated with a higher likelihood of spontaneous resolution (OR 0.963; p = 0.011). Reduction in aneurysm sac size was the strongest predictor of spontaneous closure (OR 9.706; p < 0.001), while a history of peripheral arterial disease was also favorably associated (OR 3.617; p = 0.007). Initial endoleak volume was not identified as an independent predictor (p = 0.10).
Conclusion
In patients undergoing complex endovascular repair with branched and/or fenestrated endografts, structured surveillance with CTA proved to be a safe and effective strategy for the conservative management of type III endoleaks and mixed type II/III endoleaks, provided that aneurysm sac dynamics remain stable. In this study, more than 80% of type III endoleaks resolved spontaneously at 24 months, with no aneurysm ruptures reported, allowing the avoidance of a significant number of reinterventions.
Original Title: CTA Surveillance for Conservative Endoleak Treatment following Complex Endovascular Aneurysm Repair.
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