Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland.
J Endovasc Ther. 2023 Aug;30(4):540-549. doi: 10.1177/15266028221086476. Epub 2022 Mar 30.
Endovascular aortic repair (EVAR) is widely used as an alternative to open repair in elective and even in emergent cases of ruptured abdominal aortic aneurysm (rAAA). One of the most frequent complications after EVAR is type II endoleak (T2EL). In elective therapy, evidence-based therapeutic recommendations for T2EL are limited. Completely unclear is the role of T2EL after EVAR for rAAA (rEVAR). This study aims to investigate the significance of T2ELs after rEVAR.
This is a retrospective single-center data analysis of all patients who underwent rEVAR between January 2010 and December 2020 with primary T2EL. The outcome criteria were overall and T2EL-related mortality and reintervention rate as well as development of aneurysm diameter over follow-up (FU).
During the study period between January 2010 and December 2020, 35 (25%) out of 138 patients with rEVAR presented a primary postoperative T2EL (age 74±11 years, 34 males). At rupture, mean aneurysm diameter was 73±12 mm. Follow-up was 26 (0-172) months. The reintervention-free survival was 69% (95% confidence interval [CI]: 55%-86%) at 30 days, 58% (95% CI: 43%-78%) at 1 year, and 52% (95% CI: 36%-75%) at 3 years. In 40% (n=14), T2ELs resolved spontaneously within a median time of 3.4 (0.03-85.6) months. The overall and T2EL reintervention rates were 43% (n=15) and 9% (n=3), respectively. Within 30 days, 11 patients (31%) required reintervention, of which 2 were T2EL related. Aneurysm sac growth by ≥5 mm was seen in 3 patients (9%), and aneurysm shrinkage rate was significantly higher in sealed T2EL group (86% vs 5%, p<0.0001). The overall survival was 85% (95% CI: 74%-98%) at 30 days, 75% (95% CI: 61%-92%) at 1 year, and 67% (95% CI: 51%-87%) at 3 years. Six deaths were aneurysm related, while 1 was T2EL related within the first 30 days due to persistent hemorrhage. During FU, one more patient died due to a T2EL-related secondary rupture (T2EL-related mortality, 5.7%, n=2). Multivariable analysis revealed that arterial hypertension was associated with an increased risk for reintervention (hazard ratio [HR]: 27.8, 95% CI: 1.48-521, p=0.026) and age was associated with an increased risk for mortality (HR 1.14, 95% CI: 1.04-1.26, p=0.005).
T2ELs after rEVAR showed a benign course in most cases. In the short term, the possibility of persistent bleeding should be considered. In the mid term, a consequent FU protocol is required to detect known late complications after EVAR at an early stage and to prevent secondary rupture and death.
血管内主动脉修复术（EVAR）广泛应用于择期和破裂性腹主动脉瘤（rAAA）的急诊治疗。EVAR 后最常见的并发症之一是 II 型内漏（T2EL）。在择期治疗中，对于 T2EL 的循证治疗建议有限。rEVAR 后 T2EL 的作用完全不清楚。本研究旨在探讨 rEVAR 后 T2EL 的意义。
这是一项回顾性单中心数据分析，纳入了 2010 年 1 月至 2020 年 12 月期间接受 rEVAR 治疗且初次 T2EL 的所有患者。主要转归为总体死亡率、T2EL 相关死亡率、再干预率以及随访期间（FU）动脉瘤直径的变化。
在 2010 年 1 月至 2020 年 12 月期间，138 例 rEVAR 患者中有 35 例（25%）出现原发性术后 T2EL（年龄 74±11 岁，男性 34 例）。破裂时，平均动脉瘤直径为 73±12mm。FU 时间为 26（0-172）个月。30 天无再干预生存率为 69%（95%置信区间 [CI]：55%-86%），1 年生存率为 58%（95% CI：43%-78%），3 年生存率为 52%（95% CI：36%-75%）。40%（n=14）的患者 T2EL 自发缓解，中位时间为 3.4（0.03-85.6）个月。总体和 T2EL 再干预率分别为 43%（n=15）和 9%（n=3）。30 天内，11 例患者（31%）需要再次干预，其中 2 例与 T2EL 相关。3 例患者（9%）瘤囊直径增大≥5mm，T2EL 封闭组瘤囊缩小率明显更高（86% vs 5%，p<0.0001）。30 天总体生存率为 85%（95% CI：74%-98%），1 年生存率为 75%（95% CI：61%-92%），3 年生存率为 67%（95% CI：51%-87%）。6 例死亡与动脉瘤相关，1 例死亡与 30 天内持续出血相关的 T2EL 相关（T2EL 相关死亡率为 5.7%，n=2）。多变量分析显示，高血压与再干预风险增加相关（风险比 [HR]：27.8，95% CI：1.48-521，p=0.026），年龄与死亡率风险增加相关（HR 1.14，95% CI：1.04-1.26，p=0.005）。
rEVAR 后 T2EL 大多表现为良性过程。短期内，应考虑持续出血的可能性。中期，需要进行连续的 FU 方案，以便早期发现 EVAR 后的已知晚期并发症，并预防继发性破裂和死亡。
