Toya Naoki, Kanaoka Yuji, Ohki Takao
Division of vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan,
Gen Thorac Cardiovasc Surg. 2014 Feb;62(2):87-94. doi: 10.1007/s11748-013-0333-2. Epub 2013 Oct 22.
Endovascular aneurysm repair (EVAR) of the abdominal aortic aneurysms is an attractive alternative to open surgery with significantly improved perioperative outcomes. However, EVAR is accompanied by a higher rate of graft-related complications and secondary interventions. Therefore, life-long surveillance and management of secondary treatment is essential for successful EVAR. Endoleaks are one of the most crucial problems after EVAR. Persistent endoleaks are classified into five types and its management depends on the type and severity. Most persistent endoleaks are detectable by contrast-enhanced computed tomography; however, in some cases, two different endoleak types may coexist. Determining whether an endoleak requires any treatment or not is an important consideration. Most if not all type I and III endoleaks require prompt and definitive secondary treatment. While type II endoleaks are most commonly encountered during follow-up, not all type II endoleaks require invasive treatment. When secondary treatment is required, it can be treated endovascularly in most cases, even if there is no endoleak. Following EVAR, due to the decompression of the sac, the integrity of the aneurysmal wall strength reduces. Therefore, sudden sac expansion/rupture may occur when an endoleak is encountered following a period of complete aneurysmal exclusion. If diagnosed promptly most late complications can be treated in a less invasive manner, but it could lead to catastrophic event if it is missed. Therefore, adequate and life-long radiographic follow-up is as important as the appropriate patient and device selection as well as the EVAR procedure itself.
腹主动脉瘤的血管内动脉瘤修复术（EVAR）是开放手术的一种有吸引力的替代方法，围手术期结果有显著改善。然而，EVAR伴随着更高的移植物相关并发症和二次干预发生率。因此，对二次治疗进行终身监测和管理对于EVAR的成功至关重要。内漏是EVAR后最关键的问题之一。持续性内漏分为五种类型，其管理取决于类型和严重程度。大多数持续性内漏可通过增强计算机断层扫描检测到；然而，在某些情况下，两种不同类型的内漏可能同时存在。确定内漏是否需要任何治疗是一个重要的考虑因素。大多数（如果不是全部）I型和III型内漏需要及时和明确的二次治疗。虽然II型内漏在随访期间最常遇到，但并非所有II型内漏都需要侵入性治疗。当需要二次治疗时，即使没有内漏，大多数情况下也可通过血管内治疗。EVAR后，由于瘤腔减压，动脉瘤壁强度的完整性降低。因此，在动脉瘤完全排除一段时间后遇到内漏时，可能会发生瘤腔突然扩张/破裂。如果及时诊断，大多数晚期并发症可以采用侵入性较小的方式治疗，但如果漏诊则可能导致灾难性事件。因此，充分的终身影像学随访与合适的患者和器械选择以及EVAR手术本身同样重要。
