Current assessment and management of endoleaks after advanced EVAR: new devices, new endoleaks?

ABSTRACT

Introduction

In recent years there has been an increasing application of advanced EVAR techniques to tackle complex clinical and anatomical scenarios.

In a bid to overcome the limitations of the traditional stent-grafts, newer EVAR endografts and techniques have been developed and introduced into clinical practice, permitting endovascular management of difficult infrarenal, juxta-renal and thoracoabdominal aneurysms for which previously there was no endovascular solution. As a consequence, we are now confronted with unique patterns of endoleak requiring customized clinical-radiological assessment and treatment. Despite the increasing body of evidence regarding new EVAR techniques and related endoleaks, current guidelines do not specifically address these issues.

Objectives

Our review aims to assess risk factors, development, and management strategies of these endoleaks, in the most recent infrarenal EVAR devices and in more complex fenestrated EVAR (FEVAR) and Chimney EVAR (Ch-EVAR).

Expert opinion

Most new devices have demonstrated types of endoleaks that need specific imaging and treatment, as in EVAS, FEVAR, and ChEVAR. Knowledge of specific stent-graft characteristics and the nature of endoleaks associated with the various procedures facilitates the application of relevant useful imaging. In addition, it should aid development of a customized and practically relevant approach to patient management during intervention and follow-up.

KEYWORDS:

• Aortic aneurysm
• endovascular aortic aneurysm repair
• embolization
• endoleak
• stent graft

Article highlights

• The majority of new EVAR devices are built to reduce the risk of aortic neck remodeling and type 1a endoleak.

• Due to variation in design and engineering, some new stent-grafts may be affected by specific types of endoleak

• New aortic stent-grafts may require a specific and customized follow-up protocol according to the type of endoleak

• Management of type 1a endoleak affecting new devices may be challenging and requires complex interventional radiology techniques

• Most endoleaks in Ch-EVAR and FEVAR tend to resolve spontaneously, hence a conservative observational approach may be appropriate.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. 

Additional information

Funding

This paper was not funded.