BACKGROUND: Endoluminal grafting of abdominal aortic aneurysms (AAA) has sh
own promising early results. However, endoleaks present a new and challengi
ng obstacle to successful aneurysm exclusion. We report our experience with
primary, persistent endoleaks and provide an algorithm for their diagnosis
and management.
METHODS: Over a 19-month period, 73 patients underwent endoluminal repair o
f their AAAs using a modular bifurcated endograft as part of a US FDA Inves
tigational Device Exemption trial. Spiral computed tomography (CT) scanning
was performed prior to discharge after repair to evaluate for complete ane
urysm exclusion. If no endoleak was present on that initial CT scan, color-
flow duplex scanning was performed at 1 month, with repeat CT scanning at 6
months and 1 year. If the initial CT scan revealed the presence of an endo
leak, repeat CT scanning was performed at 2 weeks, 1 month, and 3 months, o
r until the endoleak resolved. Any patient with an endoleak that persisted
beyond 3 months underwent angiographic evaluation to localize the source of
the leak.
RESULTS: At 1 month, 62 patients (85%) had successful aneurysm exclusion. T
he remaining 11 patients (15%) had primary endoleaks, 8 (11%) of which pers
isted beyond 3 months, prompting angiographic evaluation. In 2 patients the
endoleak was related to a graft-graft or graft-arterial junction. One was
from the endograft terminus in the common iliac artery and was successfully
embolized, along with its outflow lumbar artery. The other required placem
ent of an additional endograft component across a leaking graft-graft junct
ion to successfully exclude the aneurysm. The remaining six endoleaks were
due to collateral flow through the aneurysm sac. In 4 cases this was lumbar
to lumbar flow fed by hypogastric artery collaterals to the inflow lumbar
artery. In the remaining 2 patients the endoleak was found to be due to flo
w between a lumbar and inferior mesenteric artery, Resolution of the endole
ak by coil embolization of the feeding hypogastric artery branch in 1 patie
nt was unsuccessful due to rapid recruitment of another hypogastric branch.
Two of 1:he six collateral flow endoleaks have resolved spontaneously with
out treatment, while the remaining cases have been followed up without evid
ence of aneurysm expansion.
CONCLUSION: Systematic postoperative surveillance facilitates proper diagno
sis and treatment of endoleaks. This involves serial CT scans to detect the
presence of endoleaks, followed by angiography to determine their etiology
and guide treatment, if clinically indicated. (C) 1999 by Excerpta Medica,
Inc.