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Type II Endoleak and EVAR Outcomes for Abdominal Aortic Aneurysm
Quick Takes
- The cumulative incidence rates of rupture and AAA-related mortality were significantly higher in the persistent type II endoleak group.
- These results suggest that persistent type II endoleaks are not benign.
- Among patients with nonmodifiable risk factors for sac enlargement, such as older age, female sex, larger proximal neck diameter, and chronic kidney disease, and with potential for long-term survival, open surgery might be preferable.
Study Questions:
What are the results of endovascular aneurysm repair (EVAR) in patients from the Japanese Committee for Stentgraft Management (JACSM) registry, the significance of persistent type II endoleak (p-T2EL), and the risk of late adverse events including aneurysm sac enlargement?
Methods:
The investigators prospectively captured medical records of 17,099 patients aged <75 years who underwent EVAR for abdominal aortic aneurysm (AAA) from 2006-2015. Patients were divided into two groups (with or without p-T2EL) and compared to examine the correlation between p-T2EL and the occurrence of aneurysm sac enlargement after EVAR. The secondary outcome measures included reintervention-free survival, AAA-related mortality, and rupture-free survival after EVAR. The difference between each group was compared using the log-rank analysis. The patients with loss to follow-up were treated as censored observations.
Results:
Of the patients, 4,957 (29.0%) had and 12,142 (71.0%) had no p-T2EL, respectively. Mean age was significantly higher (p < 0.001) and males were fewer (p < 0.001) in the p-T2EL group. Among comorbidities, hypertension (p = 0.019) and chronic kidney disease (CKD) (p = 0.040) were more prevalent and respiratory disorders were less prevalent (p < 0.001) in the p-T2EL group. From each group, 4,957 patients were matched according to propensity score to adjust for differences in patient characteristics. The cumulative incidence rates of AAA-related mortality (p-T2EL: 52/4,957 [1.0%] vs. non-T2EL: 21/12,142 [0.2%]), rupture (p-T2EL: 38/4,957 [0.8%] vs. non-T2EL: 13/12,142 [0.1%]), sac enlargement (≥5 mm) (p-T2EL: 1,359/4,957 [27.4%] vs. non-T2EL: 332/12,142 [2.7%]), and reintervention (p-T2EL: 739/4,957 [14.9%] vs. non-T2EL: 91/12,142 [0.7%]) were significantly higher in the p-T2EL than in the non-pT2EL group (p < 0.001). Propensity score matching yielded higher estimated incremental risk, including AAA-related mortality, rupture, sac enlargement (≥5 mm), and reintervention for p-T2EL (p < 0.001). Cox regression analysis revealed older age (p = 0.010), proximal neck diameter (p = 0.003), and CKD (p < 0.001) as independent positive predictors and male sex as an independent negative predictor (p = 0.015) of sac enlargement.
Conclusions:
The authors concluded that their data show a correlation between p-T2EL and late adverse events, including aneurysm sac enlargement, reintervention, rupture, and AAA-related mortality after EVAR.
Perspective:
This study reports that the cumulative incidence rates of rupture and AAA-related mortality were significantly higher in the p-T2EL group, and the propensity score matched analysis enhanced these results. These results suggest that persistent type II endoleaks are not necessarily benign. For EVAR to achieve the same durability as that of open repair, the outcomes after EVAR should be improved, as the EVAR1 trial pointed out that rupture is most attributable to higher aneurysm-related mortality rate 8 years after EVAR. Finally, among patients with nonmodifiable risk factors for sac enlargement, such as older age, female sex, larger proximal neck diameter, and CKD, and with potential for long-term survival, open surgery might be preferable.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine, Hypertension
Keywords: Aortic Aneurysm, Abdominal, Aortic Rupture, Blood Vessel Prosthesis Implantation, Cardiology Interventions, Cardiac Surgical Procedures, Endoleak, Endovascular Procedures, Geriatrics, Hypertension, Outcome Assessment, Health Care, Renal Insufficiency, Chronic, Risk Factors, Secondary Prevention, Stents, Vascular Diseases
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