Steinmetz Eric, Rubin Brian G, Sanchez Luis A, Choi Eric T, Geraghty Patrick J, Baty Jack, Thompson Robert W, Flye M Wayne, Hovsepian David M, Picus Daniel, Sicard Gregorio A
Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
J Vasc Surg. 2004 Feb;39(2):306-13. doi: 10.1016/j.jvs.2003.10.026.
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.
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 (>or=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.
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 months, 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 US dollars 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 US dollars 200000 or more. The presence or absence of a type II endoleak did not affect survival (78% vs 73%) at 48 months.
Selective intervention to treat type II endoleak that persists for 6 months and is associated with aneurysm enlargement seems to be both safe and cost-effective. Longer follow-up will determine whether this conservative approach to management of type II endoleak is the standard of care.
腹主动脉瘤血管腔内修复术（EVAR）后对Ⅱ型内漏采用保守治疗还是积极治疗一直存在争议。本研究的目的是评估仅在Ⅱ型内漏持续超过6个月且伴有动脉瘤瘤体增大5mm或更多时才进行栓塞的保守治疗方法的安全性和成本效益。
分析486例连续接受EVAR治疗患者的Ⅱ型内漏发生率和治疗结果。回顾螺旋计算机断层扫描（CT）图像，并在门诊就诊或电话随访时评估患者的治疗结果。对新出现或迟发性Ⅱ型内漏患者每隔6个月进行一次螺旋CT检查，以评估内漏的持续情况和动脉瘤瘤体大小。对于持续（≥6个月）的Ⅱ型内漏且动脉瘤瘤体增大5mm或更多的患者，采用经腰动脉注射胶水或弹簧圈栓塞腰动脉来源，或经动脉栓塞肠系膜下动脉。
90例（18.5%）患者检测到Ⅱ型内漏。平均随访21.7±16个月，只有35例（7.2%）患者的Ⅱ型内漏持续6个月或更长时间。5例患者出现动脉瘤瘤体增大，占总病例数的1%。所有5例患者均在平均随访18.2±8.0个月时成功接受了经腰动脉瘤体栓塞（n = 4）或经动脉肠系膜下动脉栓塞（n = 4），无复发或动脉瘤瘤体增大。无论Ⅱ型内漏是否接受治疗，均无患者发生动脉瘤破裂。与动脉瘤瘤体增大相关的持续性Ⅱ型内漏的平均总治疗费用为6695.50美元（医院费用加医生报销费用）。对30例持续性Ⅱ型内漏但无动脉瘤瘤体增大的患者进行治疗将额外花费200000美元或更多。Ⅱ型内漏的有无不影响48个月时的生存率（78%对73%）。
对持续6个月且伴有动脉瘤增大的Ⅱ型内漏进行选择性干预治疗似乎既安全又具有成本效益。更长时间的随访将确定这种Ⅱ型内漏的保守治疗方法是否为标准治疗方案。
