title: Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth.
abstract: OBJECTIVE
  There is considerable controversy about the significance and appropriate treatment of type II endoleaks (T2Ls) after endovascular aneurysm repair (EVAR). We report our long-term experience with T2L management in a large multicenter registry.
  
  
  METHODS
  Between 2000 and 2010, 1736 patients underwent EVAR, and we recorded the incidence of T2L. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, major adverse events, and reintervention.
  
  
  RESULTS
  During the follow-up (median of 32.2 months; interquartile range, 14.2-52.8 months), T2L was identified in 474 patients (27.3%). There were no late abdominal aortic aneurysm ruptures attributable to a T2L. Overall mortality (P = .47) and ARM (P = .26) did not differ between patients with and without T2L. Sac growth (median, 5 mm; interquartile range, 2-10 mm) was seen in 213 (44.9%) of the patients with T2L. Of these patients with a T2L and sac growth, 36 (16.9%) had an additional type of endoleak. Of all patients with T2L, 111 (23.4%) received reinterventions, including 39 patients who underwent multiple procedures; 74% of the reinterventions were performed in patients with sac growth. Reinterventions included lumbar embolization in 66 patients (59.5%), placement of additional stents in 48 (43.2%), open surgical revision in 14 (12.6%), and direct sac injection in 22 (19.8%). The reintervention was successful in 35 patients (31.5%). After patients with other types of endoleak were excluded, no difference in overall all-cause mortality (P = .57) or ARM (P = .09) was observed between patients with T2L-associated sac growth who underwent reintervention and those in whom T2L was left untreated.
  
  
  CONCLUSIONS
  In our multicenter EVAR registry, overall all-cause mortality and ARM were unaffected by the presence of a T2L. Moreover, patients who were simply observed for T2L-associated sac growth had aneurysm-related outcomes similar to those in patients who underwent reintervention. Our future work will investigate the most cost-effective ways to select patients for intervention besides sac growth alone.
authors.affiliation: Department of Surgery, University of California, San Francisco, San Francisco, Calif.
authors.forename: Joy
authors.initials: J
authors.lastname: Walker
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, Calif.
authors.forename: Lue-Yen
authors.initials: LY
authors.lastname: Tucker
authors.affiliation: Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Philip
authors.initials: P
authors.lastname: Goodney
authors.affiliation: Department of Surgery, University of California, San Francisco-East Bay Medical Center, Oakland, Calif.
authors.forename: Leah
authors.initials: L
authors.lastname: Candell
authors.affiliation: Division of Vascular Surgery, The Permanente Medical Group, San Francisco, Calif.
authors.forename: Hong
authors.initials: H
authors.lastname: Hua
authors.affiliation: Division of Vascular Surgery, The Permanente Medical Group, San Francisco, Calif.
authors.forename: Steven
authors.initials: S
authors.lastname: Okuhn
authors.affiliation: Division of Vascular Surgery, The Permanente Medical Group, Santa Clara, Calif.
authors.forename: Bradley
authors.initials: B
authors.lastname: Hill
authors.affiliation: Division of Vascular Surgery, The Permanente Medical Group, South San Francisco, Calif. Electronic address: robert.w.chang@kp.org.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Chang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D002140:California / Q000453:epidemiology; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000401:mortality; D057867:Endoleak / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D016016:Proportional Hazards Models; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome