Aortic Endoleak Following Endovascular Aortic Repair

Post EVAR endoleak occurs in >20% of patients despite advances in technique and endograft device. Transradial access is reasonable as an initial approach to post-EVAR Type Ia and II endoleak management in appropriate patients. Complex cases or initial failure, however, may require femoral access or open repair. Type I endoleak should be repaired immediately by reballooning attachment sites and/or placement of additional stents, though persistent low-flow type 1 endoleak can be monitored conservatively as most resolve spontaneously. Type II endoleak management is a source of debate as spontaneous resolution is common and risk of rupture is low. Current recommendation suggests intervention in patients with >5 mm of interval sac expansion; however many that rupture have no evidence of expansion, leading some to treat Type II endoleak more aggressively or perform prophylactic embolization. Type III junctional endoleak is uncommon due to improved component overlap and material fatigue, but should be treated immediately with femoral delivery of additional stents to bridge the defect. Type IV endoleak is self-limiting, resolves quickly, and is not associated with long-term adverse events. Type V endoleak or endotension may be due to laminated thrombus or early generation polyester grafts and can be treated through a femoral approach by re-lining the old graft with a new bifurcated stent. Advanced fenestrated, branched, or chimney techniques may also be attempted transradially to resolve endoleak while preserving vital vessel flow, but these techniques have an increased risk of component separation regardless of access site.