134
[7]
[8]
[9]
[10]
[11]
[12]
[13]
S. Hajibandeh et al. / Interactive CardioVascular and Thoracic Surgery conservative approach with selective intervention is safe and costeffective. J Vasc Surg 2004;39:306–13. Silverberg D, Baril DT, Ellozy SH, Carroccio A, Greyrose SE, Lookstein RA et al. An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach. J Vasc Surg 2006;44:453–9. Baum RA, Carpenter JP, Golden MA, Velazquez OC, Clark TW, Stavropoulos SW et al. Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques. J Vasc Surg 2002;35:23–9. Hongo N, Kiyosue H, Shuto R, Kamei N, Miyamoto S, Tanoue S et al. Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair. J Vasc Interv Radiol 2014;25:709–16. Abularrage CJ, Patel VI, Conrad MF, Schneider EB, Cambria RP, Kwolek CJ. Improved results using Onyx glue for the treatment of persistent type 2 endoleak after endovascular aneurysm repair. J Vasc Surg 2012;56: 630–6. Massis K, Carson WG III, Rozas A, Patel V, Zwiebel B. Treatment of type II endoleaks with ethylene-vinyl-alcohol copolymer (Onyx). Vasc Endovascular Surg 2012;46:251–7. Sarac TP, Gibbons C, Vargas L, Liu J, Srivastava S, Bena J et al. Long term follow-up of type II endoleak embolisation reveals the need for close surveillance. J Vasc Surg 2012;55:33–40. Coppi G, Saitta G, Coppi G, Gennai S, Lauricella A, Silingardi R. Transealing: a novel and simple technique for embolization of type 2 endoleaks through direct sac access from the distal stent-graft landing zone. Eur J Vasc Endovasc Surg 2014;47:394–401.
rare (less than 1%), but over a third occurs in the absence of sac expansion [2]. Translumbar embolization had a higher success rate with a lower risk of complications [2]. In cases of sac expansion, the authors demonstrated that the majority of studies suggested intervention rather than surveillance without being able to define the optimal threshold for intervention. But there are some issues to be analyzed. First of all, Jouhannet et al. [3], in a retrospective study not included in the analysis, showed that 22.5% of T2ELs showed a regression of the aneurysmal sac during follow-up and 49.5% of these were stable. On the other hand, 28% continued to grow due to the coexistence of another type of endoleak [3]. Among them, 78% were treated by embolization, with 60% of them presenting with a persistent enlargement of the aneurysmal sac, even after embolization [3]. The average cost per patient that required a reintervention for T2EL was 28 096 to 30 490 € ($37 530 to $40 728) [3]. These procedures involve a high cost and high rates of morbidity, which should be taken into account in their use [3]. Moreover, Nolz et al. — after a retrospective analysis — found that despite the fact that overall sac diameter was significantly increased in the T2EL group (P = 0.007), vessel origin and the increase in the proximal neck diameter were not significantly correlated with this group [4]. The conclusion from this study was that although persistent T2EL leads to significant aneurysm sac enlargement, it is not correlated with increased mortality or rupture rates [5]. As far as the time of intervention is concerned, we also believe that it is not always clear when to intervene. But taking into consideration the study of Zhou et al. [5], who showed that patients with delayed T2EL (>1 year after EVAR) had significantly increased sac enlargement compared to T2ELs detected early, vascular surgeons should be more aggressive to intervention when they are confronted with delayed T2EL. No significant correlation was seen between the diameter of inferior mesenteric artery or lumbar to sac enlargement among the patients with a T2EL [5]. All in all, we think that beyond the time of intervention which still remains a matter of debate, the intervention itself should be applied only in cases of rapid sac enlargement or in cases of delayed T2EL. Conflict of interest: none declared.
eComment. Persistent type 2 endoleaks after endovascular aneurysm repair: why and when to intervene? Authors: Demetrios Moris, Chris Bakoyiannis and Sotirios Georgopoulos Laikon General Hospital, Athens University Medical School, Athens, Greece doi: 10.1093/icvts/ivu372 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We read with great interest the analysis of Hajibandeh et al. [1], discussing the role of intervention in type 2 endoleaks (T2EL) after endovascular aneurysm repair (EVAR). It is a common belief that T2EL still remains a concern for vascular surgeons, especially when they are associated with an enlargement of the persistent aneurysmal sac, because in this case the decision for intervention should be discussed. The experience of our centre is similar to the findings of this best-evidence topic [1] and current knowledge [2], that stable or regressive aneurysmal sac in T2EL should be managed with watchful waiting. In other words, T2ELs have a relatively benign course and, in the absence of sac expansion, can be followed-up without the need for intervention. Aortic aneurysm rupture after EVAR secondary to an isolated T2EL is
References [1] Hajibandeh S, Ahmad N, Antoniou GA, Torella F. Is intervention better than surveillance in patients with type 2 endoleak post-endovascular abdominal aortic aneurysm repair? Interact CardioVasc Thorac Surg 2015;20:128–34. [2] Sidloff DA, Stather PW, Choke E, Bown MJ, Sayers RD. Type II endoleak after endovascular aneurysm repair. Brit J Surg 2013;100:1262–70. [3] Jouhannet C, Alsac JM, Julia P, Sapoval M, El Batti S, Di Primio M et al. Reinterventions for type 2 endoleaks with enlargement of the aneurismal sac after endovascular treatment of abdominal aortic aneurysms. Ann Vasc Surg. 2014;28:192–200. [4] Nolz R, Teufelsbauer H, Asenbaum U, Beitzke D, Funovics M, Wibmer A et al. Type II endoleaks after endovascular repair of abdominal aortic aneurysms: fate of the aneurysm sac and neck changes during long-term follow-up. J Endovasc ther 2012;19:193–9. [5] Zhou W, Blay EJr., Varu V, Ali S, Jin MQ, Sun L et al. Outcome and clinical significance of delayed endoleaks after endovascular aneurysm repair. J Vasc Surg 2014;59:915–20.
[7]
[8]
[9]
[10]
[11]
[12]
[13]
S. Hajibandeh et al. / Interactive CardioVascular and Thoracic Surgery conservative approach with selective intervention is safe and costeffective. J Vasc Surg 2004;39:306–13. Silverberg D, Baril DT, Ellozy SH, Carroccio A, Greyrose SE, Lookstein RA et al. An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach. J Vasc Surg 2006;44:453–9. Baum RA, Carpenter JP, Golden MA, Velazquez OC, Clark TW, Stavropoulos SW et al. Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques. J Vasc Surg 2002;35:23–9. Hongo N, Kiyosue H, Shuto R, Kamei N, Miyamoto S, Tanoue S et al. Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair. J Vasc Interv Radiol 2014;25:709–16. Abularrage CJ, Patel VI, Conrad MF, Schneider EB, Cambria RP, Kwolek CJ. Improved results using Onyx glue for the treatment of persistent type 2 endoleak after endovascular aneurysm repair. J Vasc Surg 2012;56: 630–6. Massis K, Carson WG III, Rozas A, Patel V, Zwiebel B. Treatment of type II endoleaks with ethylene-vinyl-alcohol copolymer (Onyx). Vasc Endovascular Surg 2012;46:251–7. Sarac TP, Gibbons C, Vargas L, Liu J, Srivastava S, Bena J et al. Long term follow-up of type II endoleak embolisation reveals the need for close surveillance. J Vasc Surg 2012;55:33–40. Coppi G, Saitta G, Coppi G, Gennai S, Lauricella A, Silingardi R. Transealing: a novel and simple technique for embolization of type 2 endoleaks through direct sac access from the distal stent-graft landing zone. Eur J Vasc Endovasc Surg 2014;47:394–401.
rare (less than 1%), but over a third occurs in the absence of sac expansion [2]. Translumbar embolization had a higher success rate with a lower risk of complications [2]. In cases of sac expansion, the authors demonstrated that the majority of studies suggested intervention rather than surveillance without being able to define the optimal threshold for intervention. But there are some issues to be analyzed. First of all, Jouhannet et al. [3], in a retrospective study not included in the analysis, showed that 22.5% of T2ELs showed a regression of the aneurysmal sac during follow-up and 49.5% of these were stable. On the other hand, 28% continued to grow due to the coexistence of another type of endoleak [3]. Among them, 78% were treated by embolization, with 60% of them presenting with a persistent enlargement of the aneurysmal sac, even after embolization [3]. The average cost per patient that required a reintervention for T2EL was 28 096 to 30 490 € ($37 530 to $40 728) [3]. These procedures involve a high cost and high rates of morbidity, which should be taken into account in their use [3]. Moreover, Nolz et al. — after a retrospective analysis — found that despite the fact that overall sac diameter was significantly increased in the T2EL group (P = 0.007), vessel origin and the increase in the proximal neck diameter were not significantly correlated with this group [4]. The conclusion from this study was that although persistent T2EL leads to significant aneurysm sac enlargement, it is not correlated with increased mortality or rupture rates [5]. As far as the time of intervention is concerned, we also believe that it is not always clear when to intervene. But taking into consideration the study of Zhou et al. [5], who showed that patients with delayed T2EL (>1 year after EVAR) had significantly increased sac enlargement compared to T2ELs detected early, vascular surgeons should be more aggressive to intervention when they are confronted with delayed T2EL. No significant correlation was seen between the diameter of inferior mesenteric artery or lumbar to sac enlargement among the patients with a T2EL [5]. All in all, we think that beyond the time of intervention which still remains a matter of debate, the intervention itself should be applied only in cases of rapid sac enlargement or in cases of delayed T2EL. Conflict of interest: none declared.
eComment. Persistent type 2 endoleaks after endovascular aneurysm repair: why and when to intervene? Authors: Demetrios Moris, Chris Bakoyiannis and Sotirios Georgopoulos Laikon General Hospital, Athens University Medical School, Athens, Greece doi: 10.1093/icvts/ivu372 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We read with great interest the analysis of Hajibandeh et al. [1], discussing the role of intervention in type 2 endoleaks (T2EL) after endovascular aneurysm repair (EVAR). It is a common belief that T2EL still remains a concern for vascular surgeons, especially when they are associated with an enlargement of the persistent aneurysmal sac, because in this case the decision for intervention should be discussed. The experience of our centre is similar to the findings of this best-evidence topic [1] and current knowledge [2], that stable or regressive aneurysmal sac in T2EL should be managed with watchful waiting. In other words, T2ELs have a relatively benign course and, in the absence of sac expansion, can be followed-up without the need for intervention. Aortic aneurysm rupture after EVAR secondary to an isolated T2EL is
References [1] Hajibandeh S, Ahmad N, Antoniou GA, Torella F. Is intervention better than surveillance in patients with type 2 endoleak post-endovascular abdominal aortic aneurysm repair? Interact CardioVasc Thorac Surg 2015;20:128–34. [2] Sidloff DA, Stather PW, Choke E, Bown MJ, Sayers RD. Type II endoleak after endovascular aneurysm repair. Brit J Surg 2013;100:1262–70. [3] Jouhannet C, Alsac JM, Julia P, Sapoval M, El Batti S, Di Primio M et al. Reinterventions for type 2 endoleaks with enlargement of the aneurismal sac after endovascular treatment of abdominal aortic aneurysms. Ann Vasc Surg. 2014;28:192–200. [4] Nolz R, Teufelsbauer H, Asenbaum U, Beitzke D, Funovics M, Wibmer A et al. Type II endoleaks after endovascular repair of abdominal aortic aneurysms: fate of the aneurysm sac and neck changes during long-term follow-up. J Endovasc ther 2012;19:193–9. [5] Zhou W, Blay EJr., Varu V, Ali S, Jin MQ, Sun L et al. Outcome and clinical significance of delayed endoleaks after endovascular aneurysm repair. J Vasc Surg 2014;59:915–20.
