In a session entitled, 'Visceral aneurysm and endoleak' presented at the Global Embolization Symposium and Technologies (GEST) meeting, Dr Jafar Golzarian, University of Iowa, Iowa City, US, discussed the role of embolisation for type I endoleak after endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm (AAA).
Golzarian opened his talk by explaining the classification of endoleaks. Type I to V are classified based on the origin of the endoleak, said Golzarian. Type I can also be classified as "ineffective sealing of the proximal or the distal end of the stent graft to the aortic or iliac wall."
In addressing the issue of embolisation of type I endoleak, Golzarian asked the following questions:
• Does thrombosis protect from rupture?
• Does embolisation work?
• How to embolise?
• When to embolise?
He then referred to the EUROSTAR Data Registry Centre, (Department of Vascular Surgery, Eindhoven, The Netherlands) and a study by Cuypers et al, 1999 entitled, 'Realistic expectations for patients with stent-graft treatment of abdominal aortic aneurysms. Results of a European multicentre registry', which assessed the outcomes for patients after endovascular treatment of AAA, determined primarily by the endpoints of death and endoleaks, (the latter representing continued risk of rupture).
Thirty eight European institutions of vascular surgery collaborating in a multi-centre registry project were involved. Eight hundred and ninety nine patients with AAA underwent elective endovascular repair (818 men and 81 women; mean age, 69 years) between May 1994 and March 1998. It was reported that 80 (8.9%) of the patients had medical conditions that excluded them from open repair. According to the authors, the maximum transverse diameter (MTD) in patients with temporary endoleaks demonstrated a significant decrease at six to 12 months compared to preoperative values (mean 57 and 53 respectively, p=0.004). In patients with persistent endoleaks there was no change between the preoperative and six-month MTD (mean 57 and 60mm, respectively). At six and 18 months freedom-from-endoleak was 83% and 74% and freedom-from-persistent endoleak was 93% and 90%, respectively. The 18-month cumulative patient survival was 88% and the main outcome measure, the persistent endoleak-free-survival was 79%.
From the data presented in the paper, Golzarian concluded that patients with type I endoleak sealed spontaneously had the same evolution than patients without leak, and only persistent leaks were associated with an increase in diameter.
Following, Golzarian referred to personal data when he asked whether embolisation of type I endoleak works? His initial experience involved eight patients, and he explained that embolisation stopped aneurismal expansion during three to nine months follow-up in patients with long-standing leak. No major complications were observed.
Golzarian then referred to two studies, one by Amesure et al., 1999, which evaluated six patients with endoleak resolution, and the other by Gorich et al., 2000, involving 13 patients with endoleak resolution (6.8 months of follow-up). He also stated that there were two new papers in 2005 demonstrating the efficacy of embolisation in type I endoleak.
In another personal study, 32 patients (28 males, four females; mean age 73 years) with persistent type I endoleak were treated by transcatheter embolisation. All patients were considered as high risk for surgery.
Golzarian reported that "Thrombosis of the perigraft leaks occurred in 29 patients after 36 procedures. Failure occurred in three patients. Six patients were lost to the follow-up." Four deaths transpired (from seven - 90 days) unrelated to the procedure. Aneurysm size decreased in 15 patients, was stable in five patients and increased in two patients with persistent endoleak.
Golzarian concluded that embolisation for type I is associated with long-term success. It is a less invasive alternative and treatment choice in type IC. He also stated that embolisation can be the last resort in type IA.
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