1. Type II Endoleaks: When and How
to Treat
Dr Simon Neequaye
Advanced Endovascular Surgery Fellow
McGill University and Jewish General Hospital

2. Plan
• Review the incidence and clinical significance of
type 2 endoleaks
• Review treatment options and results of such
therapies

3. ‘persistent blood flow outside the graft and
within the aneurysm sac.’

9. signficance of Endoleaks
• 60 % of complications after EVAR
• 45 % of all re-interventions
• Type 2 Endoleak more common than all other types of
endoleak combined
EVAR trial participants. Endovascular aneurysm repair versus open repair
inpatients with abdominal aortic aneurysm (EVAR trial 1): randomised
controlled trial. Lancet. 2005 Jun 25-Jul 1;365(9478):2179-86.

10. Are we failing to adequately treat some
patients?

12. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.
Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur J
Vasc Endovasc Surg. 2009 Jan;37(1):15-22. doi: 10.1016/j.ejvs.2008.10.011.
Epub 2008 Nov 12.
• Endoleaks were described
as the main cause of
rupture in 160 of 235(70 %)
of patients with ruptured
AAA following infra-renal
EVAR.

13. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.
Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur J
Vasc Endovasc Surg. 2009 Jan;37(1):15-22. doi: 10.1016/j.ejvs.2008.10.011.
Epub 2008 Nov 12.
• Endoleaks were described
as the main cause of
rupture in 160 of 235(70 %)
of patients with ruptured
AAA following infra-renal
EVAR.

14. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.
Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur J
Vasc Endovasc Surg. 2009 Jan;37(1):15-22. doi: 10.1016/j.ejvs.2008.10.011.
Epub 2008 Nov 12.
• Endoleaks were described
as the main cause of
rupture in 160 of 235(70 %)
of patients with ruptured
AAA following infra-renal
EVAR.

15. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.
Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur J
Vasc Endovasc Surg. 2009 Jan;37(1):15-22. doi: 10.1016/j.ejvs.2008.10.011.
Epub 2008 Nov 12.
• Endoleaks were described
as the main cause of
rupture in 160 of 235(70 %)
of patients with ruptured
AAA following infra-renal
EVAR.

16. Type 1 Type 3
• High Pressure Endoleaks present an obvious
problem.

17. Type 2

19. • Type 2 Endoleak on post operative CTA 1 in 3 patients
(at least 1 month post op)
1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaks
after endovascular repair of abdominal aortic aneurysm are not always a benign
condition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.
Epub 2013 Mar 7.

20. 1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaks
after endovascular repair of abdominal aortic aneurysm are not always a benign
condition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.
Epub 2013 Mar 7.

21. 1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaks
after endovascular repair of abdominal aortic aneurysm are not always a benign
condition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.
Epub 2013 Mar 7.

22. 1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaks
after endovascular repair of abdominal aortic aneurysm are not always a benign
condition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.
Epub 2013 Mar 7.

23. 1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaks
after endovascular repair of abdominal aortic aneurysm are not always a benign
condition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.
Epub 2013 Mar 7.

24. • Pre-operative embolisation of lumbars or IMA had no effect on
incidence of T2E (23 patients)
• No difference in presence of type I or Type III endoleak
between the two groups ( T2E 24 % vs no T2E 27% p=0.8)
1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaks
after endovascular repair of abdominal aortic aneurysm are not always a benign
condition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.
Epub 2013 Mar 7.

25. • Recurrent as well as Persistent Type 2 endoleak
leads to aneurysm sac enlargement and life-
threatening complications.
• These should be closely monitored to ensure early
and specific treatment.
1: El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaks
after endovascular repair of abdominal aortic aneurysm are not always a benign
condition. J Vasc Surg. 2013 May;57(5):1291-7. doi: 10.1016/j.jvs.2012.10.118.
Epub 2013 Mar 7.

26. Post EVAR imaging is mandatory

28. • Surveillance tests
★ Duplex
★ CTA
★ Plain Xray
Post EVAR imaging
Monitor sac size and device integrity

29. • Special tests-
★ Contrast enhanced Ultrasound
★ MRI
★ Catheter Angiography
Post EVAR imaging
Delineate source of endoleak

30. Colour Duplex scan of patient with sac enlargement from 7cm to
7.5 cm

31. Colour Duplex scan of patient with sac enlargement from 7cm to
7.5 cm

32. Treatment of Type 2 Endoleak
• Occlude Feeding vessels
★Trans-arterial embolisation
★Surgical ligation of feeding vessels (Open or Laparoscopic)
• Induction of Sac Thrombosis
• Open conversion.

33. Trans-Arterial embolisation of IMA via SMA

34. Trans-Arterial embolisation of IMA via SMA

35. Trans-Arterial embolisation of IMA via SMA

36. Trans-Arterial embolisation of IMA via SMA

37. Trans-arterial via Ilio-lumbar
route

39. Direct Aneurysm puncture
• Trans peritoneal
★ 22-gauge Chiba needle
★ USS guided
• Trans Lumbar
★ Fluoroscopic or CT guidance

40. Embolisation agents
• Detachable coils
• Cyanoacrylate glue
• Thrombin
• Onyx

43. • 60 % require multiple procedures
• Isolated IMA source of embolisation results in 72 % freedom
from re-intervention at 2 years
• Success of initial intervention for lumbar endoleak was 17 %,
with a 40 % success following secondary interventions.
Gallagher KA, Ravin RA, Meltzer AJ, Khan MA, Coleman DM, Graham AR, Aiello
F,Shrikhande G, Connolly PH, Dayal R, Karwowski JK. Midterm outcomes after
treatment of type II endoleaks associated with aneurysm sac expansion. J
Endovasc Ther. 2012 Apr;19(2):182-92.
Results of Trans arterial
embolisation

45. Onyx glue embolization was associated with a greater success rate when
used as the initial secondary intervention
(odds ratio, 59.61; 95% confidence interval, 4.78-742.73; P < .001).

46. Onyx glue embolization was associated with a greater success rate when
used as the initial secondary intervention
(odds ratio, 59.61; 95% confidence interval, 4.78-742.73; P < .001).
2

47. Approximately 50 x price
of gold
Onyx glue embolization was associated with a greater success rate when
used as the initial secondary intervention
(odds ratio, 59.61; 95% confidence interval, 4.78-742.73; P < .001).
2

48. • Aggressive laparascopic approach with clipping of
all branches followed by evacuation of sac and
oversewing of remaining branches.
• 60 % sac growth at 6 years followup.

49. 1: Phade SV, Keldahl ML, Morasch MD, Rodriguez HE, Pearce WH, Kibbe MR, Eskandari
MK. Late abdominal aortic endograft explants: indications and outcomes. Surgery.
2011 Oct;150(4):788-95.
2: Marone EM, Mascia D, Coppi G, Tshomba Y, Bertoglio L, Kahlberg A, Chiesa R.
Delayed Open Conversion after Endovascular Abdominal Aortic Aneurysm:
Device-specific Surgical Approach. Eur J Vasc Endo
3:Forbes TL, Harrington DM, Harris JR, DeRose G. Late conversion of endovascular
to open repair of abdominal aortic aneurysms. Can J Surg. 2012 Aug;55(4):254-8.
• Supraceliac control usually required
• Mortality 2-13 %
• Morbidity 30 %
Open conversion

50. Other approaches

55. Conclusion:
1)We Know Type 2 Endoleaks can cause sac expansion.
2)We Think we should treat some of them
•Sac expansion >5mm
•Persistent Type 2 Endoleak??
3)Our current Embolisation techniques are Probably not
effective in the long term management of Type 2 Endoleaks.

56. QuickTime™ and a
decompressor
are needed to see this picture.

57. Thank you.