title: Treatment of Type II Endoleak and Aneurysm Expansion after EVAR.
abstract: BACKGROUND
  The management of type II endoleak causing sac enlargement continues to be a topic of debate. The purpose of this study was to examine and compare the outcomes between open surgical technique with sacotomy and suturing of the feeding vessels to interventional embolization in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR).
  
  
  METHODS
  Inclusion criteria for intervention in patients with prior EVAR and type II endoleak were asymptomatic expanding aneurysm sac > 5 mm between 2 consecutive follow-up computed tomography angiography scans and symptomatic aneurysm sac expansion. Age, sex, comorbidities, clinical presentation, commercial type of endograft of prior EVAR, aneurysm sac increase, type of treatment, morbidity, mortality, and follow-up were also recorded.
  
  
  RESULTS
  A total of 694 consecutive patients were operated with EVAR during the study period. Among them, 29 patients (4.2%) were presented with a type II endoleak that required reintervention. Ten patients (34.5%) were treated with embolization. We recorded a 50% technical success in the group of primary translumbar embolization and 67% in the group of intra-arterial embolization. Twenty-two patients were treated with laparotomy and open ligation of the culprit arteries causing the type II endoleak. Among them, 3 patients (13.6%) had been initially treated with unsuccessful embolization. Periprocedural intervention complications for the embolization group (10%, 1/10) included 1 psoas hematoma. On the contrary, complications after primary open ligation were 13.6% (3/22) and included 1 proximal dislocation treated with endograft explantation, 1 distal dislocation, and 1 limb ligation with femoral-femoral bypass which resulted in colonic ischemia and death (4.5%).
  
  
  CONCLUSIONS
  Open surgical repair with sacotomy and suturing of the feeding vessels appeared to have better outcome regarding the exclusion of the aneurysm but was associated with a higher incidence of severe complications and one related death. If these results are confirmed in larger series, endovascular approach should be the preferred treatment option.
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece. Electronic address: konmoulakakis@yahoo.gr.
authors.forename: Konstantinos G
authors.initials: KG
authors.lastname: Moulakakis
authors.affiliation: Division of Vascular Surgery, First Department of Surgery, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
authors.forename: Christos
authors.initials: C
authors.lastname: Klonaris
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: John
authors.initials: J
authors.lastname: Kakisis
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: Constantine N
authors.initials: CN
authors.lastname: Antonopoulos
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: Andreas
authors.initials: A
authors.lastname: Lazaris
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: George S
authors.initials: GS
authors.lastname: Sfyroeras
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Mantas
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: Spyridon N
authors.initials: SN
authors.lastname: Vasdekis
authors.affiliation: Department of Radiology, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: Elias N
authors.initials: EN
authors.lastname: Brountzos
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Geroulakos
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / 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; D016208:Databases, Factual; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000401:mortality; D057867:Endoleak / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006115:Greece; D006801:Humans; D008026:Ligation; D008297:Male; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013536:Suture Techniques / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome