title: Management of endoleak after endovascular aneurysm repair: cuffs, coils, and conversion.
abstract: OBJECTIVE
  The effectiveness of endovascular treatment of abdominal aortic aneurysm (AAA) may be limited by persistent perfusion of the aneurysm sac (endoleak). Endoleak that results in persistent systemic pressurization of the aneurysm or in continued AAA expansion is believed to require treatment to prevent rupture. This report describes the results of three techniques used to treat endoleak.
  
  
  METHODS
  Endovascular repair of AAA was performed in 597 patients between January 1996 and September 2002. Seventy-three endoleaks that required treatment developed in 70 patients (11.7%). These involved the graft attachment site (type I) or the graft junction site (type III) or originated from collateral side-branch vessels (type II) and were associated with an increase in aneurysm size. Endoleak type was confirmed at angiography in all cases. Average time between the initial endovascular procedure and endoleak treatment was 14.5 +/- 5.7 months. The techniques used for endoleak treatment were deployment of an endovascular extension graft or cuff (n = 44), coil embolization (n = 24,) and conversion to conventional open repair (n = 5). Configurations of endovascular grafts in which endoleak developed were bifurcated (n = 44), aortouniiliac (n = 15), and aortoaortic-tube (n = 11). Mean follow-up after endoleak treatment was 24.5 +/- 12.2 months (range, 1-60 months).
  
  
  RESULTS
  Endovascular extension grafts or cuffs were used to treat 41 attachment site endoleaks and 3 graft junction endoleaks, with overall technical success rate of 97%. Embolic coils were used to treat 16 retrograde side-branch endoleaks and 8 attachment site endoleaks, with overall technical success rate of 87%. Conversion to open surgery was performed in 4 patients with attachment site endoleaks and 1 patient with a graft junction site endoleak, and was successful in all cases. After endoleak treatment, aneurysm size decreased (>5 mm) in 38% of patients, stabilized in 58% of patients, and increased (>5 mm) in 4% of patients. Major morbidity occurred in 7.0%, with no perioperative deaths.
  
  
  CONCLUSIONS
  Endovascular extension grafts, coil embolization, and conversion to open surgery each may be used to effectively repair endoleak. Selection of the treatment method used is determined by the anatomic characteristics of the endoleak and the patient's ability to tolerate conventional repair. Conversion to open repair was uniformly successful. Deployment of an extension cuff was successful when complete closure of the endoleak was achieved. Embolic coils were effective for retrograde endoleaks and provided stabilization of AAA size in selected patients with attachment site endoleaks in limited follow-up.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, New York Presbyterian Hospital, Weill-Cornell Medical School, 525 E 68th St, Rm P705, New York, NY 10021, USA. plf2001@med.cornell.edu
authors.forename: Peter L
authors.initials: PL
authors.lastname: Faries
authors.forename: Hadley
authors.initials: H
authors.lastname: Cadot
authors.forename: Gautam
authors.initials: G
authors.lastname: Agarwal
authors.forename: K Craig
authors.initials: KC
authors.lastname: Kent
authors.forename: Larry H
authors.initials: LH
authors.lastname: Hollier
authors.forename: Michael L
authors.initials: ML
authors.lastname: Marin
mesh_terms: D000368:Aged; D015901:Angiography, Digital Subtraction; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D004621:Embolization, Therapeutic; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D011475:Prosthesis Failure; D012086:Reoperation; D015607:Stents; D013525:Surgical Instruments; D013997:Time Factors