title: Freedom from endoleak after endovascular aneurysm repair does not equal treatment success.
abstract: OBJECTIVE
  To determine whether freedom from endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) is a reliable guide to freedom from persistent or recurrent pressurisation of the aneurysm sac (endotension) and therefore freedom from risk of rupture.
  
  
  METHODS
  The records of 55 patients followed for more than 3 months after EVAR were reviewed to correlate the presence or absence of endoleak on contrast-enhanced CT and/or angiography with changes in maximum aneurysm diameter (DMAX).
  
  
  RESULTS
  in 22 (40%) patients there was no significant change in DMAX during follow-up. In 21 of these no endoleak was observed on CT or angiography. One patient developed a secondary side-branch endoleak which remains under observation. In 18 (33%) patients, DMAX decreased during follow-up. Thirteen of these remained free of endoleak. Four patients developed secondary endoleaks which were treated by secondary intervention. One patient with persistent primary endoleak suffered fatal aneurysm rupture three days before planned intervention. DMAX increased in 15 (27%) patients. In only five of these could an endoleak be identified on CT and/or angiography. One primary side-branch endoleak persists following failed embolisation. Four secondary endoleaks have been corrected by secondary intervention. Four of the remaining 10 patients died suddenly from unknown cause. All had DMAX greater than 65 mm at last follow-up. One patient underwent late conversion, which suggested continued pressurisation through thrombus at the site of a "sealed" primary proximal endoleak. Two patients are scheduled to undergo embolisation of patent side-branches revealed only by Levovist enhanced Duplex scanning and three patients remain under observation.
  
  
  CONCLUSIONS
  Freedom from endoleak on conventional imaging incorrectly suggested freedom from endotension in 10 (18%) of our patients. Follow-up after endovascular repair must include regular measurement of DMAX and/or aneurysm sac volume to identify those patients who remain at risk of rupture.
authors.affiliation: Regional Vascular Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, UK.
authors.forename: G L
authors.initials: GL
authors.lastname: Gilling-Smith
authors.forename: J
authors.initials: J
authors.lastname: Martin
authors.forename: S
authors.initials: S
authors.lastname: Sudhindran
authors.forename: D A
authors.initials: DA
authors.lastname: Gould
authors.forename: R G
authors.initials: RG
authors.lastname: McWilliams
authors.forename: A
authors.initials: A
authors.lastname: Bakran
authors.forename: J A
authors.initials: JA
authors.lastname: Brennan
authors.forename: P L
authors.initials: PL
authors.lastname: Harris
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001012:Aorta, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000517:prevention & control*; D011475:Prosthesis Failure; D012086:Reoperation; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome