title: The natural history of type II endoleaks after endovascular aneurysm repair for ruptured abdominal aortic aneurysm.
abstract: OBJECTIVE
  The natural history of type II endoleak (T2EL) after endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) remains elusive; as such, treatment guidelines are ill defined. The purpose of this study was to better delineate the natural history of T2EL after EVAR for rAAA in an effort to determine the need for reintervention and optimal surveillance.
  
  
  METHODS
  A retrospective record review was conducted of all patients undergoing EVAR for rAAA in two large tertiary care academic vascular centers. Patient demographics, comorbidities, anatomic variables, and operative details were analyzed. Primary outcomes included the presence of T2EL, reintervention, delayed rupture, and aneurysm-related death.
  
  
  RESULTS
  EVAR was used to treat rAAA in 56 patients between 2000 and 2013. Mean follow-up of this cohort was 634 days. Completion arteriogram demonstrated T2ELs in 12 patients (21%), and an additional four T2ELs (7%) were found by postoperative computed tomography angiogram that were not identified on the completion angiogram. Body mass index was the only statistically significant variable associated with the development of T2EL (P = .03). Preoperative warfarin use, aortic thrombus burden, and device type did not correlate with T2EL development. Iliolumbar vessels supplied 75% (n = 12) of T2ELs. Of the 14 patients with T2ELs who underwent serial imaging postoperatively, six (43%) sealed spontaneously. Five patients (36%) underwent reintervention for T2EL by way of coil embolization-four in which treatment was initiated by attending preference. One patient was treated for ongoing anemia in the immediate postoperative period. There was no sac expansion, delayed rupture, or graft explantation.
  
  
  CONCLUSIONS
  T2ELs after EVAR for rAAA are common and appear to be associated with a benign natural history if left untreated. Although many will spontaneously seal early in the postoperative period, those that remain patent do not appear to increase the risk for sac expansion or delayed rupture or affect patient survival. As such, a conservative approach to treatment of T2ELs in rAAA may be warranted.
authors.affiliation: Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Anna E
authors.initials: AE
authors.lastname: Boniakowski
authors.affiliation: Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Randall R
authors.initials: RR
authors.lastname: De Martino
authors.affiliation: Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Coleman
authors.affiliation: Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Eliason
authors.affiliation: Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Phillip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Tex. Electronic address: john.rectenwald@utsouthwestern.edu.
authors.forename: John E
authors.initials: JE
authors.lastname: Rectenwald
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D000072226:Computed Tomography Angiography; D004621:Embolization, Therapeutic; D057867:Endoleak / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008824:Michigan; D008875:Middle Aged; D009513:New Hampshire; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome