Advertisement

Editor's Choice – Systematic Review and Meta-Analysis of the Outcome of Treatment for Type II Endoleak Following Endovascular Aneurysm Repair

Open ArchivePublished:August 10, 2018DOI:https://doi.org/10.1016/j.ejvs.2018.06.009

      Objectives

      The efficacy and need for secondary interventions for type II endoleaks following endovascular abdominal aortic aneurysm repair (EVAR) remain controversial. This systematic review aimed at investigating the clinical outcomes of different type II endoleak treatments in patients with a persistent type II endoleak after EVAR.

      Data sources

      Embase, Medline via Ovid, Web of Science Core Collection, the Cochrane CENTRAL, and Google Scholar.

      Review methods

      This systematic review was performed in accordance with the PRISMA Statement. Outcomes of interest were technical and clinical success, change in sac diameter, complications, need for additional interventions, abdominal aortic aneurysm (AAA) rupture, and (AAA related) mortality. Meta-analyses were performed with random effects models.

      Results

      A total of 59 studies were included, with a cumulative cohort of 1073 patients with persistent type II endoleak. Peri-operative complications following treatment of type II endoleaks occurred in 3.8% of patients (95% CI 2.7–5.2%), and AAA related mortality was 1.8% (95% CI 1.1–2.7%). Overall technical success was 87.9% (95% CI 83.1–92.1%), while clinical success was 68.4% (95% CI 61.2–75.1%). Among studies detailing sac dynamics, decrease or stable sac, with or without resolution, was achieved in 78.4% (95% CI 70.2–85.6%). Changes in sac diameter following type II endoleak treatment were documented in 157 patients to at least 24 months. Within this group an actual decrease in sac diameter was reported in only 27 of 40 patients.

      Conclusion

      There is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although generally safe, the lack of evidence supporting the efficacy of type II endoleak treatment leads to difficulty in assessing its merits.

      Keywords

      The efficacy and need for secondary intervention for type II endoleaks following endovascular abdominal aortic aneurysm repair remain controversial. This systematic review and meta-analysis shows that despite routine performance, there is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although the currently available techniques are reported to be generally safe, the clinical course after intervention may not be different from conservative treatment.

      Introduction

      The beneficial peri-operative outcomes of endovascular repair (EVAR) for abdominal aortic aneurysm (AAA)
      • Schermerhorn M.L.
      • O'Malley A.J.
      • Jhaveri A.
      • Cotterill P.
      • Pomposelli F.
      • Landon B.E.
      Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population.
      • Prinssen M.
      • Verhoeven E.L.
      • Buth J.
      • Cuypers P.W.
      • van Sambeek M.R.
      • Balm R.
      • et al.
      A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.
      • Lederle F.A.
      • Freischlag J.A.
      • Kyriakides T.C.
      • Padberg Jr., F.T.
      • Matsumura J.S.
      • Kohler T.R.
      • et al.
      Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.
      • Greenhalgh R.M.
      • Brown L.C.
      • Kwong G.P.
      • Powell J.T.
      • Thompson S.G.
      Participants Et
      Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial.
      have resulted in a rapid increase in its use since its introduction in 1991.
      • Kent K.C.
      Clinical practice. Abdominal aortic aneurysms.
      • Parodi J.C.
      • Palmaz J.C.
      • Barone H.D.
      Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.
      Currently in many countries, over 80% of infrarenal AAA repairs are performed endovascularly.
      • Schermerhorn M.L.
      • Bensley R.P.
      • Giles K.A.
      • Hurks R.
      • O'Malley A.J.
      • Cotterill P.
      • et al.
      Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995–2008: a retrospective observational study.
      • Chadi S.A.
      • Rowe B.W.
      • Vogt K.N.
      • Novick T.V.
      • Harris J.R.
      • Derose G.
      • et al.
      Trends in management of abdominal aortic aneurysms.
      • Lederle F.A.
      • Freischlag J.A.
      • Kyriakides T.C.
      • Matsumura J.S.
      • Padberg Jr., F.T.
      • Kohler T.R.
      • et al.
      Long-term comparison of endovascular and open repair of abdominal aortic aneurysm.
      Despite the early advantages of the technique, EVAR has more delayed AAA related complications.
      • Patel R.
      • Sweeting M.J.
      • Powell J.T.
      • Greenhalgh R.M.
      Investigators Et
      Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial.
      • Schermerhorn M.L.
      • Buck D.B.
      • O'Malley A.J.
      • Curran T.
      • McCallum J.C.
      • Darling J.
      • et al.
      Long-term outcomes of abdominal aortic aneurysm in the medicare population.
      Among these, there is the potential for endoleaks, in which the aneurysm is not completely excluded from the circulation because of persistent blood flow within the aneurysm sac. Of the various types of endoleaks, general consensus exists on the relevance of type I and III, which are considered life threatening conditions that require secondary intervention. The significance of type II endoleaks, however, is not so clear. These are the most common type of endoleaks, with a reported occurrence rate between 8% and 44%.
      • Gelfand D.V.
      • White G.H.
      • Wilson S.E.
      Clinical significance of type II endoleak after endovascular repair of abdominal aortic aneurysm.
      • Choke E.
      • Thompson M.
      Endoleak after endovascular aneurysm repair: current concepts.
      Although the pathophysiology by which branch vessels provide arterial perfusion of the aneurysm sac is well understood, the clinical significance and thus the necessity for their treatment continues to be a topic of debate.
      Over the years it has become clearer that the risk of aneurysm rupture in the presence of an isolated type II endoleak is exceptionally low.
      • Sidloff D.A.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak after endovascular aneurysm repair.
      This has led to the general practice that only type II endoleaks in the presence of aneurysm growth are a potential target for treatment.
      • Sidloff D.A.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak after endovascular aneurysm repair.
      • Moll F.L.
      • Powell J.T.
      • Fraedrich G.
      • Verzini F.
      • Haulon S.
      • Waltham M.
      • et al.
      Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery.
      • Chaikof E.L.
      • Brewster D.C.
      • Dalman R.L.
      • Makaroun M.S.
      • Illig K.A.
      • Sicard G.A.
      • et al.
      SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary.
      Aside from conservative management, there are a variety of treatment options that may be considered when a type II endoleak is diagnosed, all with their inherent flaws and advantages. First, the endoleak can be approached through a transarterial catheter, which enables embolisation using coils, thrombin, or glue. As an alternative, the aneurysm sac may be approached directly through a translumbar or transcaval route. Furthermore, the collateral vessels giving rise to the endoleak can be ligated either through an open transabdominal or laparoscopic procedure. Employing any of these techniques remains controversial, because of the unclear benefit on the one hand, and the risk of doing harm on the other. Furthermore, the true success rate of this treatment remains mostly unknown as usually only the immediate technical success of the procedure is reported, the definition of success varies per study, and the effect of type II endoleak treatment on sac size is usually not reported.
      This systematic review investigated the peri-operative and mid- to long-term clinical outcomes of different type II endoleak treatments in patients with a persistent type II endoleak after EVAR. In particular, the review aimed at analysing aneurysm sac dynamics after endoleak motivated interventions, as well as potential mortality and morbidity caused by such interventions.

      Methods

      Literature search

      A systematic review was performed in accordance with the PRISMA Statement (http://www.prisma-statement.org).
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Group P.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      Embase, Medline via Ovid, Web of Science Core Collection, the Cochrane CENTRAL, and Google Scholar, were all comprehensively reviewed with the help of a medical librarian using the search terms provided in the supplementary documentation (Table S1). The last search was conducted on the June 26, 2017.

      Study selection

      The titles and abstracts of the retrieved articles were independently reviewed by two reviewers. Disagreements were discussed with a third reviewer. All studies reporting on the outcome of interventions for type II endoleaks with a minimum follow up of 6 months were initially included. Exclusion criteria were non-abdominal aneurysms, publication date before 2000, and non-English language. Additionally, studies were excluded if they did not distinguish type II endoleak outcomes from endoleaks from other sources. Case reports demonstrating the technical feasibility of secondary re-intervention were also excluded, because of the possibility of publication bias. The initial goal was to examine studies with a minimum follow up of 12 months, and report on changes in sac diameter following type II endoleak intervention. However, too few studies met these requirements, so it was decided to expand the inclusion criteria. Instead, sub-analyses were performed in accordance with follow up time and sac dynamics.

      Data extraction

      Two reviewers (KU and SB) working independently determined eligibility, and extracted descriptive, methodological, and outcome data from each eligible study, using a standard form. The reviewers extracted the following from each study: publication year, method of type II endoleak treatment, criteria for intervention, median or mean follow up, technical success rate, clinical success rate, change in sac diameter, complications, need for additional interventions, AAA rupture, and AAA related mortality. After data extraction, values were evaluated by a third researcher (RH). Technical success was defined as resolution of the previously identified backflow on post-operative imaging. The definition of clinical success varied between studies, and included lack of sac enlargement, sac diameter decrease, absence of flow on follow up imaging, and resolution or lack of flow in the aneurysm sac on follow up imaging. The definition was therefore individually detailed.

      Quality assessment

      To compare the quality of the included studies, the Newcastle-Ottowa Quality Assessment Scale was used (KU and SB). Studies with a score below 6 were excluded, because of insufficient quality. All studies met this quality standard, therefore further scoring was omitted (Table S2).

      Outcome assessment

      To account for the potential inter-study heterogeneity, random effects modelling was used to estimate the proportion of technical success, clinical success, as well as adverse outcomes. Statistical heterogeneity was assessed using the I2 statistic, which quantifies the proportion of total variance observed between the studies attributable to differences between the studies rather than chance. Pooled results are presented as percentages with 95% CI. Analyses were performed using MedCalc Version 18 (MedCalc Software, Ostend, Belgium).

      Results

      The electronic search yielded 1876 potentially relevant research papers. After applying the exclusion criteria, 59 studies were considered suitable for inclusion (Table 1, Fig. 1). This group of studies included 54 retrospective studies, four prospectively conducted studies, and one multicentre study. A total of 1073 patients with persistent type II endoleak who underwent one or more interventions for type II endoleak were included in this review.
      Table 1Study characteristics.
      StudyYearMethod of treatmentNo. of patientsCriteria for treatmentFollow up after treatment, monthsTotal follow up, monthsMedian time to treatment, months
      Arko
      • Arko F.R.
      • Filis K.A.
      • Siedel S.A.
      • Johnson B.L.
      • Drake A.R.
      • Fogarty T.J.
      • et al.
      Intrasac flow velocities predict sealing of type II endoleaks after endovascular abdominal aortic aneurysm repair.
      2003Transarterial embolisation6Persistence and high velocities13.630.216.6
      Aziz
      • Aziz A.
      • Menias C.O.
      • Sanchez L.A.
      • Picus D.
      • Saad N.
      • Rubin B.G.
      • et al.
      Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion.
      2012Translumbar/transarterial embolisation42Sac expansion22.648.425.8
      Baum
      • Baum R.A.
      • Carpenter J.P.
      • Golden M.A.
      • Velazquez O.C.
      • Clark T.W.I.
      • Stavropoulous S.W.
      • et al.
      Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.
      2002Transarterial embolisation20Type II endoleak13.1N.S.N.S.
      Baum
      • Baum R.A.
      • Carpenter J.P.
      • Golden M.A.
      • Velazquez O.C.
      • Clark T.W.I.
      • Stavropoulous S.W.
      • et al.
      Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.
      2002Translumbar embolisation13Type II endoleak8.4N.S.N.S.
      Beeman
      • Beeman B.R.
      • Murtha K.
      • Doerr K.
      • McAfee-Bennett S.
      • Dougherty M.J.
      • Calligaro K.D.
      Duplex ultrasound factors predicting persistent type II endoleak and increasing AAA sac diameter after EVAR.
      2010Translumbar/transarterial embolisation/open ligation11Sac expansionN.S.65.0N.S.
      Buckenham
      • Buckenham T.
      • McKewen M.
      • Laing A.
      • Roake J.
      • Lewis D.
      • Gordon M.K.
      Cyanoacrylate embolization of endoleaks after abdominal aortic aneurysm repair.
      2009Transarterial embolisation4Sac expansion10.3N.S.26.4
      Carrafiello
      • Carrafiello G.
      • Ierardi A.M.
      • Radaelli A.
      • De Marchi G.
      • Floridi C.
      • Piffaretti G.
      • et al.
      Unenhanced cone beam computed tomography and fusion imaging in direct percutaneous sac injection for treatment of type II endoleak: technical note.
      2016Translumbar embolisation8Sac expansion37.0N.S.N.S.
      Chikazawa
      • Chikazawa G.
      • Hiraoka A.
      • Hirai Y.
      • Tamura K.
      • Totsugawa T.
      • Ishida A.
      • et al.
      Open reintervention for aneurysmal sac enlargement after EVAR.
      2014Open ligation7Sac expansion6.6N.S.43.0
      Cho
      • Cho J.S.
      • Dillavou E.D.
      • Rhee R.Y.
      • Makaroun M.S.
      Late abdominal aortic aneurysm enlargement after endovascular repair with the excluder device.
      2004Transarterial embolisation2Sac expansionN.S.48.0N.S.
      Cieri
      • Cieri E.
      • De Rango P.
      • Isernia G.
      • Simonte G.
      • Ciucci A.
      • Parlani G.
      • et al.
      Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair.
      2014Various embolisation techniques52Sac expansionN.S.45.0N.S.
      Coppi
      • Coppi G.
      • Saitta G.
      • Coppi G.
      • Gennai S.
      • Lauricella A.
      • Silingardi R.
      Transealing: a novel and simple technique for embolization of type 2 endoleaks through direct sac access from the distal stent-graft landing zone.
      2014Transarterial technique17Sac expansion21.5N.S.50.0
      Dobes
      • Dobes D.
      • Hajek M.
      • Raupach J.
      • Belobradek Z.
      • Kuriakose J.
      • Arestis N.
      Surgical treatment of the progressive endoleak type II after EVAR.
      2016Open ligation10Sac expansion12N.S.N.S.
      El Batti
      • El Batti S.
      • Cochennec F.
      • Roudot-Thoraval F.
      • Becquemin J.P.
      Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition.
      2013Transarterial embolisation31N.S.N.S.36.7N.S.
      Faries
      • Faries P.L.
      • Cadot H.
      • Agarwal G.
      • Kent K.C.
      • Hollier L.H.
      • Marin M.L.
      Management of endoleak after endovascular aneurysm repair: cuffs, coils, and conversion.
      2003Transarterial embolisation16Sac expansion24.5N.S.12.3
      Ford
      • Ford C.A.
      • Lange B.B.
      • Morris C.S.
      Transcatheter embolization of abdominal aortic endograft endoleaks using onyx and coils: midterm imaging follow-up.
      2017Transarterial/CT/fluoroscopic guided embolisation14Sac expansion13.2N.S.13.3
      Fujimura
      • Fujimura N.
      • Obara H.
      • Matsubara K.
      • Watada S.
      • Shibutani S.
      • Akiyoshi T.
      • et al.
      Characteristics and risk factors for type 2 endoleak in an east asian population from a Japanese multicenter database.
      2015Transarterial embolisation11Sac expansion16.0N.S.22.4
      Funaki
      • Funaki B.
      • Birouti N.
      • Zangan S.M.
      • Van Ha T.G.
      • Lorenz J.M.
      • Navuluri R.
      • et al.
      Evaluation and treatment of suspected type II endoleaks in patients with enlarging abdominal aortic aneurysms.
      2012Transarterial embolisation16Sac expansion27.5N.S.48.0
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Transarterial embolisation11Sac expansion42.0N.S.N.S.
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Translumbar embolisation17Sac expansion42.0N.S.N.S.
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Laparoscopic clipping1Sac expansion42.0N.S.N.S.
      Gandini
      • Gandini R.
      • Chiocchi M.
      • Loreni G.
      • Del Giudice C.
      • Morosetti D.
      • Chiaravalloti A.
      • et al.
      Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.
      2014Nonselective transcaval embolisation9Sac expansion25.9N.S.12.3
      Gandini
      • Gandini R.
      • Chiocchi M.
      • Loreni G.
      • Del Giudice C.
      • Morosetti D.
      • Chiaravalloti A.
      • et al.
      Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.
      2014Selective transcaval embolisation20Sac expansion24.1N.S.12.3
      Giles
      • Giles K.A.
      • Fillinger M.F.
      • De Martino R.R.
      • Hoel A.W.
      • Powell R.J.
      • Walsh D.B.
      Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair.
      2015Transcaval embolisation26Sac expansion16.5N.S.N.S.
      Goerich
      • Görich J.
      • Rilinger N.
      • Sokiranski R.
      • Krämer S.
      • Schütz A.
      • Sunder-Plassmann L.
      • et al.
      Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric artery approach.
      2000Transarterial embolisation11Type II endoleak24.5N.S.N.S.
      Haq
      • Haq I.U.
      • Kelay A.
      • Davis M.
      • Brookes J.
      • Mastracci T.M.
      • Constantinou J.
      Ten-year single-centre experience with type II endoleaks: intervention versus observation.
      2017Transarterial embolisation17Surgeon's discretionN.S.37.32N.S.
      Haq
      • Haq I.U.
      • Kelay A.
      • Davis M.
      • Brookes J.
      • Mastracci T.M.
      • Constantinou J.
      Ten-year single-centre experience with type II endoleaks: intervention versus observation.
      2017Translumbar embolisation11Surgeon's discretionN.S.37.32N.S.
      Haulon
      • Haulon S.
      • Tyazi A.
      • Willoteaux S.
      • Koussa M.
      • Lions C.
      • Beregi J.P.
      Embolization of type II endoleaks after aortic stent-graft implantation: technique and immediate results.
      2001Superselective catheterisation18Type II endoleak13.3N.S.N.S.
      Higashiura
      • Higashiura W.
      • Greenberg R.K.
      • Katz E.
      • Geiger L.
      • Bathurst S.
      Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms.
      2007Transarterial embolisation11N.S.N.S.24.0N.S.
      Hongo
      • Hongo N.
      • Kiyosue H.
      • Shuto R.
      • Kamei N.
      • Miyamoto S.
      • Tanoue S.
      • et al.
      Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair.
      2014Transarterial embolisation20Sac expansion18.5N.S.N.S.
      Ishibashi
      • Ishibashi H.
      • Ishiguchi T.
      • Ohta T.
      • Sugimoto I.
      • Iwata H.
      • Yamada T.
      • et al.
      Late events and mid-term results after endovascular aneurysm repair.
      2014Transarterial embolisation3Sac expansionN.S.27.5N.S.
      Jones
      • Jones J.E.
      • Atkins M.D.
      • Brewster D.C.
      • Chung T.K.
      • Kwolek C.J.
      • LaMuraglia G.M.
      • et al.
      Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.
      2007Translumbar/transarterial/open ligation16Sac expansionN.S.43.1 N.S.N.S.
      Kasirajan
      • Kasirajan K.
      • Matteson B.
      • Marek J.M.
      • Langsfeld M.
      Technique and results of transfemoral superselective coil embolization of type II lumbar endoleak.
      2003Superselective catheterisation8Sac expansion9.0N.S.N.S.
      Kim
      • Kim M.H.
      • Park H.S.
      • Ahn S.
      • Min S.I.
      • Min S.K.
      • Ha J.
      • et al.
      Chronological change of the sac after endovascular aneurysm repair.
      2016Transarterial embolisation16various (majority sac growth)N.S.N.S.27.3
      Kumar
      • Kumar L.
      • Cowled P.
      • Boult M.
      • Howell S.
      • Fitridge R.
      Type II endoleak after endovascular aneurysm repair: natural history and treatment outcomes.
      2017Various embolisation techniques16Persistence and sac expansionN.S.22.8N.S.
      Liewald
      • Liewald F.
      • Ermis C.
      • Görich J.
      • Halter G.
      • Scharrer-Pamler R.
      • Sunder-Plassmann L.
      Influence of treatment of type II leaks on the aneurysm surface area.
      2001Transarterial embolisation14type II endoleakN.S.18.0N.S.
      Maitrias
      • Maitrias P.
      • Kaladji A.
      • Plissonnier D.
      • Amiot S.
      • Sabatier J.
      • Coggia M.
      • et al.
      Treatment of sac expansion after endovascular aneurysm repair with obliterating endoaneurysmorrhaphy and stent graft preservation.
      2016Open ligation21Sac expansion24.0N.S.24.0
      Maitrias
      • Maitrias P.
      • Belhomme D.
      • Molin V.
      • Reix T.
      Obliterative endoaneurysmorrhaphy with stent graft preservation for treatment of type II progressive endoleak.
      2016Open ligation10Sac expansion12.0N.S.12.0
      Mansueto
      • Mansueto G.
      • Cenzi D.
      • Scuro A.
      • Gottin L.
      • Griso A.
      • Gumbs A.A.
      • et al.
      Treatment of type II endoleak with a transcatheter transcaval approach: results at 1-year follow-up.
      2007Transcatheter transcaval embolisation12Persistence12.0N.S.47.0
      Marcelin
      • Marcelin C.
      • Le Bras Y.
      • Petitpierre F.
      • Midy D.
      • Ducasse E.
      • Grenier N.
      • et al.
      Safety and efficacy of embolization using Onyx® of persistent type II endoleaks after abdominal endovascular aneurysm repair.
      2017Transarterial embolisation/Direct puncture embolisation28Persistence and sac expansion >5 mmN.S.N.S.26
      Martin
      • Martin M.L.
      • Dolmatch B.L.
      • Fry P.D.
      • Machan L.S.
      Treatment of type II endoleaks with Onyx.
      2001Transarterial embolisation4Persistence7.1N.S.18.1
      Moulakakis
      • Moulakakis K.G.
      • Klonaris C.
      • Kakisis J.
      • Antonopoulos C.N.
      • Lazaris A.
      • Sfyroeras G.S.
      • et al.
      Treatment of type II endoleak and aneurysm expansion after EVAR.
      2017Transarterial/translumbar embolisation10Sac expansion31.2N.S.32.3
      Moulakakis
      • Moulakakis K.G.
      • Klonaris C.
      • Kakisis J.
      • Antonopoulos C.N.
      • Lazaris A.
      • Sfyroeras G.S.
      • et al.
      Treatment of type II endoleak and aneurysm expansion after EVAR.
      2017Open ligation19Sac expansion20.1N.S.37.2
      Müller-Wille
      • Müller-Wille R.
      • Wohlgemuth W.A.
      • Heiss P.
      • Wiggermann P.
      • Güntner O.
      • Schreyer A.G.
      • et al.
      Transarterial embolization of type II endoleaks after EVAR: the role of ethylene vinyl alcohol copolymer (Onyx).
      2013Transarterial embolisation11Sac expansion26.0N.S.20.5
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Transarterial embolisation10Sac expansionN.S.54.0N.S.
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Translumbar embolisation3Sac expansionN.S.54.0N.S.
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Transabdominal embolisation1Sac expansionN.S.54.0N.S.
      Parry
      • Parry D.J.
      • Kessel D.O.
      • Robertson I.
      • Denton L.
      • Patel J.V.
      • Berridge D.C.
      • et al.
      Type II endoleaks: predictable, preventable, and sometimes treatable?.
      2002Transarterial embolisation6Persistence without sac shrinkageN.S.24.0N.S.
      Piffaretti
      • Piffaretti G.
      • Franchin M.
      • Botteri E.
      • Boni L.
      • Carrafiello G.
      • Battaglia G.
      • et al.
      Operative treatment of type 2 endoleaks involving the inferior mesenteric artery.
      2017Laparoscopic ligation11Persistent leak or sac expansion46N.S.N.S.
      Piffaretti
      • Piffaretti G.
      • Franchin M.
      • Botteri E.
      • Boni L.
      • Carrafiello G.
      • Battaglia G.
      • et al.
      Operative treatment of type 2 endoleaks involving the inferior mesenteric artery.
      2017Transarterial embolisation10Persistent leak or sac expansion46N.S.N.S.
      Quinones
      • Quinones-Baldrich W.
      • Levin E.S.
      • Lew W.
      • Barleben A.
      Intraprocedural and postprocedural perigraft arterial sac embolization (PASE) for endoleak treatment.
      2014Perigraft arterial embolisation1Sac expansion23.1N.S.40.1
      Rayt
      • Rayt H.S.
      • Sandford R.M.
      • Salem M.
      • Bown M.J.
      • London N.J.
      • Sayers R.D.
      Conservative management of type 2 endoleaks is not associated with increased risk of aneurysm rupture.
      2009Various embolisation techniques1Sac expansionN.S.N.S.36.0
      Rial
      • Rial R.
      • Serrano F.J.
      • Vega M.
      • Rodriguez R.
      • Martin A.
      • Mendez J.
      • et al.
      Treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysms: translumbar puncture and injection of thrombin into the aneurysm sac.
      2004Translumbar embolisation3>6 months6.0N.S.N.S.
      Ribe
      • Ribe L.
      • Bicknell C.D.
      • Gibbs R.G.
      • Burfitt N.
      • Jenkins M.P.
      • Cheshire N.
      • et al.
      Long-term results of intra-arterial onyx injection for type II endoleaks following endovascular aneurysm repair.
      2017Transarterial embolisation18Sac expansion19N.S.N.S.
      Richardson
      • Richardson W.S.
      • Sternbergh Iii, W.C.
      • Money S.R.
      Laparoscopic inferior mesenteric artery ligation: an alternative for the treatment of type II endoleaks.
      2003Transarterial embolisation or laparoscopic ligation4Sac expansion16.0N.S.2.5
      Sarac
      • Sarac T.P.
      • Gibbons C.
      • Vargas L.
      • Liu J.
      • Srivastava S.
      • Bena J.
      • et al.
      Long-term follow-up of type II endoleak embolization reveals the need for close surveillance.
      2012Various embolisation techniques95Sac expansion>24.0N.S.26.1
      Scali
      • Scali S.T.
      • Vlada A.
      • Chang C.K.
      • Beck A.W.
      Transcaval embolization as an alternative technique for the treatment of type II endoleak after endovascular aortic aneurysm repair.
      2013Transcaval embolisation6>6 months + sac expansion8.1N.S.52.0
      Silverberg
      • Silverberg D.
      • Baril D.T.
      • Ellozy S.H.
      • Carroccio A.
      • Greyrose S.E.
      • Lookstein R.A.
      • et al.
      An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach.
      2006Transfemoral/translumbar embolisation19Surgeon's discretionN.S.N.S.19.9
      Stavropoulos
      • Stavropoulos S.W.
      • Park J.
      • Fairman R.
      • Carpenter J.
      Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization.
      2009Translumbar embolisation62Sac expansion20.2N.S.N.S.
      Stavropoulos
      • Stavropoulos S.W.
      • Park J.
      • Fairman R.
      • Carpenter J.
      Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization.
      2009Modified transarterial embolisation23Sac expansion17.3N.S.N.S.
      Steinmetz
      • Steinmetz E.
      • Rubin B.G.
      • Sanchez L.A.
      • Choi E.T.
      • Geraghty P.J.
      • Baty J.
      • et al.
      Type II endoleak after endovascular abdominal aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective.
      2004Translumbar/transarterial embolisation5Sac expansionN.S.N.S.18.2
      Tolia
      • Tolia A.J.
      • Landis R.
      • Lamparello P.
      • Rosen R.
      • Macari M.
      Type II endoleaks after endovascular repair of abdominal aortic aneurysms: natural history.
      2005Transarterial embolisation2Sac expansion36.0N.S.N.S.
      Tutein
      • Tutein Nolthenius R.P.
      • Van Herwaarden J.A.
      • Van den Berg J.C.
      • Van Marrewijk C.
      • Teijink J.A.W.
      • Moll F.L.
      Three year single centre experience with the AneuRx aortic stent graft.
      2001Translumbar/transarterial embolisation4N.S.N.S.N.S.N.S.
      Van Bindsbergen
      • Van Bindsbergen L.
      • Braak S.J.
      • Van Strijen M.J.L.
      • De Vries J.P.P.M.
      Type II endoleak embolization after endovascular abdominal aortic aneurysm repair with use of real-time three-dimensional fluoroscopic needle guidance.
      2010Translumbar embolisation5Sac expansion7.0N.S.N.S.
      Van Lammeren
      • Van Lammeren G.W.
      • Fioole B.
      • Waasdorp E.J.
      • Moll F.L.
      • Van Herwaarden J.A.
      • De Vries J.P.P.M.
      Long-term follow-up of secondary interventions after endovascular aneurysm repair with the AneuRx endoprosthesis: a single-center experience.
      2010Transarterial embolisation8Sac expansion >5 mmN.S.81.029.0
      Voute
      • Voûte M.T.
      • Bastos Gonçalves F.M.
      • Hendriks J.M.
      • Metz R.
      • Van Sambeek M.R.H.M.
      • Muhs B.E.
      • et al.
      Treatment of post-implantation aneurysm growth by laparoscopic sac fenestration: long-term results.
      2013Laparoscopic fenestration4Sac expansion45.6N.S.19.8
      Walker
      • Walker J.
      • Tucker L.Y.
      • Goodney P.
      • Candell L.
      • Hua H.
      • Okuhn S.
      • et al.
      Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth.
      2015Various embolisation techniques82Sac expansionN.S.32.29.0
      Wojtaszek
      • Wojtaszek M.
      • Wnuk E.
      • Maciag R.
      • Solonynko B.
      • Korzeniowski K.
      • Lamparski K.
      • et al.
      Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx.
      2017Transarterial embolisation22Persistence and sac expansion176043
      Yamada
      • Yamada M.
      • Takahashi H.
      • Tauchi Y.
      • Satoh H.
      • Matsuda H.
      Open surgical repair can Be one option for the treatment of persistent type II endoleak after EVAR.
      2015Open ligation5Sac expansion16.2N.S.17.6
      Yang
      • Yang R.Y.
      • Tan K.T.
      • Beecroft J.R.
      • Rajan D.K.
      • Jaskolka J.D.
      Direct sac puncture versus transarterial embolization of type II endoleaks: an evaluation and comparison of outcomes.
      2017Transarterial or direct puncture embolisation23Sac expansion21.8N.S17.7
      Total10736.0–46.018.0–81.02.5–52.0
      N.S. = not stated.
      The time to treatment varied from 2.5 to 52.0 months after the initial procedure. In the majority of cases (73.8%; 792/1073), sac expansion was the indication for attempting to resolve the type II endoleak. Secondary intervention for the type II endoleak was performed at the surgeon's discretion in 4.4% (47/1073) of patients, persistent endoleak with or without sac expansion was the indication for 18.6% (200/1073), and 4.3% (46/1073) of the studies did not state the exact indication for the procedure.

      Technical and clinical success

      Although the exact definition of technical success was often not stated, the most commonly employed definition was no evidence of flow entering the aneurysm sac at the end of the procedure. Among the 50 studies detailing technical success, 87.9% (95% CI 83.1–92.1%; I2 = 72.2%) of procedures were deemed technically successful (Table 2). Stratification by type of procedure, where possible, demonstrated high technical success rates for all techniques. For trans-arterial embolisation procedures, technical success was 84.0% (77.2–89.8%; I2 = 56.2%), while for translumbar, and transcaval embolisation, this was 98.7% (95% CI 95.6–100%; I2 = 0.0%) and 93.3% (95% CI 85.1–98.4; I2 = 27.1%), respectively. Branch vessel interruption, either through a laparoscopic or open procedure, also proved to be very successful with a technical success rate of 98.1% (95% CI 94.3–100%; I2 = 0.0%).
      Table 2Effectiveness of surgical intervention for type II endoleak.
      StudyYearMethod of treatmentNo. of patientsTechnical successSac diam. decreasedSac diam. stableSac growthClinical successDefinition clinical success
      Arko
      • Arko F.R.
      • Filis K.A.
      • Siedel S.A.
      • Johnson B.L.
      • Drake A.R.
      • Fogarty T.J.
      • et al.
      Intrasac flow velocities predict sealing of type II endoleaks after endovascular abdominal aortic aneurysm repair.
      2003Transarterial embolisation66N.S.N.S.N.S.5Flow velocity and resolution
      Aziz
      • Aziz A.
      • Menias C.O.
      • Sanchez L.A.
      • Picus D.
      • Saad N.
      • Rubin B.G.
      • et al.
      Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion.
      2012Translumbar/transarterial embolisation42N.S.N.S.N.S.N.S.11Resolution
      Baum
      • Baum R.A.
      • Carpenter J.P.
      • Golden M.A.
      • Velazquez O.C.
      • Clark T.W.I.
      • Stavropoulous S.W.
      • et al.
      Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.
      2002Transarterial embolisation2017N.S.N.S.N.S.4Resolution
      Baum
      • Baum R.A.
      • Carpenter J.P.
      • Golden M.A.
      • Velazquez O.C.
      • Clark T.W.I.
      • Stavropoulous S.W.
      • et al.
      Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.
      2002Translumbar embolisation1313N.S.N.S.N.S.12Resolution
      Beeman
      • Beeman B.R.
      • Murtha K.
      • Doerr K.
      • McAfee-Bennett S.
      • Dougherty M.J.
      • Calligaro K.D.
      Duplex ultrasound factors predicting persistent type II endoleak and increasing AAA sac diameter after EVAR.
      2010Translumbar/transarterial embolisation/open ligation11N.S.5N.S.65Resolution
      Buckenham
      • Buckenham T.
      • McKewen M.
      • Laing A.
      • Roake J.
      • Lewis D.
      • Gordon M.K.
      Cyanoacrylate embolization of endoleaks after abdominal aortic aneurysm repair.
      2009Transarterial embolisation441301Resolution
      Carrafiello
      • Carrafiello G.
      • Ierardi A.M.
      • Radaelli A.
      • De Marchi G.
      • Floridi C.
      • Piffaretti G.
      • et al.
      Unenhanced cone beam computed tomography and fusion imaging in direct percutaneous sac injection for treatment of type II endoleak: technical note.
      2016Translumbar embolisation883508Resolution or stability of sac
      Chikazawa
      • Chikazawa G.
      • Hiraoka A.
      • Hirai Y.
      • Tamura K.
      • Totsugawa T.
      • Ishida A.
      • et al.
      Open reintervention for aneurysmal sac enlargement after EVAR.
      2014Open ligation77N.S.N.S.07Lack of sac enlargement
      Cho
      • Cho J.S.
      • Dillavou E.D.
      • Rhee R.Y.
      • Makaroun M.S.
      Late abdominal aortic aneurysm enlargement after endovascular repair with the excluder device.
      2004Transarterial embolisation220020Lack of sac enlargement
      Cieri
      • Cieri E.
      • De Rango P.
      • Isernia G.
      • Simonte G.
      • Ciucci A.
      • Parlani G.
      • et al.
      Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair.
      2014Various embolisation techniques52N.S.N.S.N.S.2230Lack of sac enlargement
      Coppi
      • Coppi G.
      • Saitta G.
      • Coppi G.
      • Gennai S.
      • Lauricella A.
      • Silingardi R.
      Transealing: a novel and simple technique for embolization of type 2 endoleaks through direct sac access from the distal stent-graft landing zone.
      2014Transarterial technique17165338Lack of sac enlargement and resolution
      Dobes
      • Dobes D.
      • Hajek M.
      • Raupach J.
      • Belobradek Z.
      • Kuriakose J.
      • Arestis N.
      Surgical treatment of the progressive endoleak type II after EVAR.
      2016Open ligation1010N.S.N.S.N.S.10Resolution
      El Batti
      • El Batti S.
      • Cochennec F.
      • Roudot-Thoraval F.
      • Becquemin J.P.
      Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition.
      2013Transarterial embolisation31N.S.N.S.N.S.247Lack of sac enlargement
      Faries
      • Faries P.L.
      • Cadot H.
      • Agarwal G.
      • Kent K.C.
      • Hollier L.H.
      • Marin M.L.
      Management of endoleak after endovascular aneurysm repair: cuffs, coils, and conversion.
      2003Transarterial embolisation16145N.S.N.S.N.S.N.S.
      Ford
      • Ford C.A.
      • Lange B.B.
      • Morris C.S.
      Transcatheter embolization of abdominal aortic endograft endoleaks using onyx and coils: midterm imaging follow-up.
      2017Transarterial/CT/fluoroscopic-guided embolisation14148157Resolution
      Fujimura
      • Fujimura N.
      • Obara H.
      • Matsubara K.
      • Watada S.
      • Shibutani S.
      • Akiyoshi T.
      • et al.
      Characteristics and risk factors for type 2 endoleak in an east asian population from a Japanese multicenter database.
      2015Transarterial embolisation11104254Resolution
      Funaki
      • Funaki B.
      • Birouti N.
      • Zangan S.M.
      • Van Ha T.G.
      • Lorenz J.M.
      • Navuluri R.
      • et al.
      Evaluation and treatment of suspected type II endoleaks in patients with enlarging abdominal aortic aneurysms.
      2012Transarterial embolisation1614N.S.N.S.016Lack of sac enlargement
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Transarterial embolisation11N.S.N.S.N.S.N.S.8Resolution
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Translumbar embolisation17N.S.N.S.N.S.N.S.3Resolution
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Laparoscopic clipping1N.S.N.S.N.S.N.S.0Resolution
      Gandini
      • Gandini R.
      • Chiocchi M.
      • Loreni G.
      • Del Giudice C.
      • Morosetti D.
      • Chiaravalloti A.
      • et al.
      Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.
      2014Nonselective transcaval embolisation99N.S.N.S.N.S.5Resolution
      Gandini
      • Gandini R.
      • Chiocchi M.
      • Loreni G.
      • Del Giudice C.
      • Morosetti D.
      • Chiaravalloti A.
      • et al.
      Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.
      2014Selective transcaval embolisation2020N.S.N.S.N.S.20Resolution
      Giles
      • Giles K.A.
      • Fillinger M.F.
      • De Martino R.R.
      • Hoel A.W.
      • Powell R.J.
      • Walsh D.B.
      Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair.
      2015Transcaval embolisation2622N.S.N.S.818Lack of sac enlargement
      Goerich
      • Görich J.
      • Rilinger N.
      • Sokiranski R.
      • Krämer S.
      • Schütz A.
      • Sunder-Plassmann L.
      • et al.
      Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric artery approach.
      2000Transarterial embolisation1111N.S.N.S.N.S.11Resolution
      Haq
      • Haq I.U.
      • Kelay A.
      • Davis M.
      • Brookes J.
      • Mastracci T.M.
      • Constantinou J.
      Ten-year single-centre experience with type II endoleaks: intervention versus observation.
      2017Transarterial embolisation17N.S.25102Resolution
      Haq
      • Haq I.U.
      • Kelay A.
      • Davis M.
      • Brookes J.
      • Mastracci T.M.
      • Constantinou J.
      Ten-year single-centre experience with type II endoleaks: intervention versus observation.
      2017Translumbar embolisation11N.S.0383Resolution
      Haulon
      • Haulon S.
      • Tyazi A.
      • Willoteaux S.
      • Koussa M.
      • Lions C.
      • Beregi J.P.
      Embolization of type II endoleaks after aortic stent-graft implantation: technique and immediate results.
      2001Superselective catheterisation1817135016Resolution
      Higashiura
      • Higashiura W.
      • Greenberg R.K.
      • Katz E.
      • Geiger L.
      • Bathurst S.
      Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms.
      2007Transarterial embolisation11N.S.N.S.N.S.N.S.7Resolution
      Hongo
      • Hongo N.
      • Kiyosue H.
      • Shuto R.
      • Kamei N.
      • Miyamoto S.
      • Tanoue S.
      • et al.
      Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair.
      2014Transarterial embolisation2018214216Sac expansion <5 mm
      Ishibashi
      • Ishibashi H.
      • Ishiguchi T.
      • Ohta T.
      • Sugimoto I.
      • Iwata H.
      • Yamada T.
      • et al.
      Late events and mid-term results after endovascular aneurysm repair.
      2014Transarterial embolisation33N.S.N.S.03Lack of sac enlargement
      Jones
      • Jones J.E.
      • Atkins M.D.
      • Brewster D.C.
      • Chung T.K.
      • Kwolek C.J.
      • LaMuraglia G.M.
      • et al.
      Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.
      2007Translumbar/transarterial/open ligation16N.S.N.S.N.S.N.S.9Resolution
      Kasirajan
      • Kasirajan K.
      • Matteson B.
      • Marek J.M.
      • Langsfeld M.
      Technique and results of transfemoral superselective coil embolization of type II lumbar endoleak.
      2003Superselective catheterisation886116Sac diameter decrease
      Kim
      • Kim M.H.
      • Park H.S.
      • Ahn S.
      • Min S.I.
      • Min S.K.
      • Ha J.
      • et al.
      Chronological change of the sac after endovascular aneurysm repair.
      2016Transarterial embolisation169N.S.N.S.N.S.5Lack of sac enlargement
      Kumar
      • Kumar L.
      • Cowled P.
      • Boult M.
      • Howell S.
      • Fitridge R.
      Type II endoleak after endovascular aneurysm repair: natural history and treatment outcomes.
      2017Various embolisation techniques16156206Sac diameter decrease
      Liewald
      • Liewald F.
      • Ermis C.
      • Görich J.
      • Halter G.
      • Scharrer-Pamler R.
      • Sunder-Plassmann L.
      Influence of treatment of type II leaks on the aneurysm surface area.
      2001Transarterial embolisation148N.S.N.S.45Resolution
      Maitrias
      • Maitrias P.
      • Kaladji A.
      • Plissonnier D.
      • Amiot S.
      • Sabatier J.
      • Coggia M.
      • et al.
      Treatment of sac expansion after endovascular aneurysm repair with obliterating endoaneurysmorrhaphy and stent graft preservation.
      2016Open ligation2121210021Resolution
      Maitrias
      • Maitrias P.
      • Belhomme D.
      • Molin V.
      • Reix T.
      Obliterative endoaneurysmorrhaphy with stent graft preservation for treatment of type II progressive endoleak.
      2016Open ligation1010100010Resolution
      Mansueto
      • Mansueto G.
      • Cenzi D.
      • Scuro A.
      • Gottin L.
      • Griso A.
      • Gumbs A.A.
      • et al.
      Treatment of type II endoleak with a transcatheter transcaval approach: results at 1-year follow-up.
      2007Transcatheter transcaval embolisation121110N.S.N.S.10Sac diameter decrease
      Marcelin
      • Marcelin C.
      • Le Bras Y.
      • Petitpierre F.
      • Midy D.
      • Ducasse E.
      • Grenier N.
      • et al.
      Safety and efficacy of embolization using Onyx® of persistent type II endoleaks after abdominal endovascular aneurysm repair.
      2017Transarterial embolisation/direct Puncture embolisation286522127Lack of sac enlargement
      Martin
      • Martin M.L.
      • Dolmatch B.L.
      • Fry P.D.
      • Machan L.S.
      Treatment of type II endoleaks with Onyx.
      2001Transarterial embolisation434004Sac diameter decrease
      Moulakakis
      • Moulakakis K.G.
      • Klonaris C.
      • Kakisis J.
      • Antonopoulos C.N.
      • Lazaris A.
      • Sfyroeras G.S.
      • et al.
      Treatment of type II endoleak and aneurysm expansion after EVAR.
      2017Transarterial/translumbar Embolisation108N.S.N.S.N.S.7Resolution
      Moulakakis
      • Moulakakis K.G.
      • Klonaris C.
      • Kakisis J.
      • Antonopoulos C.N.
      • Lazaris A.
      • Sfyroeras G.S.
      • et al.
      Treatment of type II endoleak and aneurysm expansion after EVAR.
      2017Open ligation1919N.S.N.S.N.S.17Resolution
      Müller-Wille
      • Müller-Wille R.
      • Wohlgemuth W.A.
      • Heiss P.
      • Wiggermann P.
      • Güntner O.
      • Schreyer A.G.
      • et al.
      Transarterial embolization of type II endoleaks after EVAR: the role of ethylene vinyl alcohol copolymer (Onyx).
      2013Transarterial embolisation1163538Lack of sac enlargement
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Transarterial embolisation104N.S.N.S.N.S.6Resolution of leak without enlargement
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Translumbar embolisation33N.S.N.S.N.S.2Resolution of leak without enlargement
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Transabdominal embolisation11N.S.N.S.N.S.0Resolution of leak without enlargement
      Parry
      • Parry D.J.
      • Kessel D.O.
      • Robertson I.
      • Denton L.
      • Patel J.V.
      • Berridge D.C.
      • et al.
      Type II endoleaks: predictable, preventable, and sometimes treatable?.
      2002Transarterial embolisation633003Lack of sac enlargement
      Piffaretti
      • Piffaretti G.
      • Franchin M.
      • Botteri E.
      • Boni L.
      • Carrafiello G.
      • Battaglia G.
      • et al.
      Operative treatment of type 2 endoleaks involving the inferior mesenteric artery.
      2017Laparoscopic ligation1111N.S.N.S.N.S.9Resolution
      Piffaretti
      • Piffaretti G.
      • Franchin M.
      • Botteri E.
      • Boni L.
      • Carrafiello G.
      • Battaglia G.
      • et al.
      Operative treatment of type 2 endoleaks involving the inferior mesenteric artery.
      2017Transarterial embolisation1010N.S.N.S.N.S.7Resolution
      Quinones
      • Quinones-Baldrich W.
      • Levin E.S.
      • Lew W.
      • Barleben A.
      Intraprocedural and postprocedural perigraft arterial sac embolization (PASE) for endoleak treatment.
      2014Perigraft arterial embolisation11010N.S.N.S.
      Rayt
      • Rayt H.S.
      • Sandford R.M.
      • Salem M.
      • Bown M.J.
      • London N.J.
      • Sayers R.D.
      Conservative management of type 2 endoleaks is not associated with increased risk of aneurysm rupture.
      2009Various embolisation techniques100010Lack of sac enlargement
      Rial
      • Rial R.
      • Serrano F.J.
      • Vega M.
      • Rodriguez R.
      • Martin A.
      • Mendez J.
      • et al.
      Treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysms: translumbar puncture and injection of thrombin into the aneurysm sac.
      2004Translumbar embolisation33N.S.N.S.N.S.3Resolution
      Ribe
      • Ribe L.
      • Bicknell C.D.
      • Gibbs R.G.
      • Burfitt N.
      • Jenkins M.P.
      • Cheshire N.
      • et al.
      Long-term results of intra-arterial onyx injection for type II endoleaks following endovascular aneurysm repair.
      2017Transarterial embolisation1818N.S.N.S.N.S.15resolution
      Richardson
      • Richardson W.S.
      • Sternbergh Iii, W.C.
      • Money S.R.
      Laparoscopic inferior mesenteric artery ligation: an alternative for the treatment of type II endoleaks.
      2003Transart. embolisation or laparoscopic ligation434004Lack of sac enlargement
      Sarac
      • Sarac T.P.
      • Gibbons C.
      • Vargas L.
      • Liu J.
      • Srivastava S.
      • Bena J.
      • et al.
      Long-term follow-up of type II endoleak embolization reveals the need for close surveillance.
      2012Various embolisation techniques9572N.S.N.S.5342Resolution
      Scali
      • Scali S.T.
      • Vlada A.
      • Chang C.K.
      • Beck A.W.
      Transcaval embolization as an alternative technique for the treatment of type II endoleak after endovascular aortic aneurysm repair.
      2013Transcaval embolisation66N.S.114Resolution
      Silverberg
      • Silverberg D.
      • Baril D.T.
      • Ellozy S.H.
      • Carroccio A.
      • Greyrose S.E.
      • Lookstein R.A.
      • et al.
      An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach.
      2006Transfemoral/translumbar embolisation1916N.S.N.S.411Resolution
      Stavropoulos
      • Stavropoulos S.W.
      • Park J.
      • Fairman R.
      • Carpenter J.
      Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization.
      2009Translumbar embolisation6262N.S.N.S.1045Lack of sac enlargement
      Stavropoulos
      • Stavropoulos S.W.
      • Park J.
      • Fairman R.
      • Carpenter J.
      Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization.
      2009Modified transarterial embolisation2322N.S.N.S.318Lack of sac enlargement
      Steinmetz
      • Steinmetz E.
      • Rubin B.G.
      • Sanchez L.A.
      • Choi E.T.
      • Geraghty P.J.
      • Baty J.
      • et al.
      Type II endoleak after endovascular abdominal aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective.
      2004Translumbar/transarterial embolisation55N.S.N.S.N.S.5Resolution
      Tolia
      • Tolia A.J.
      • Landis R.
      • Lamparello P.
      • Rosen R.
      • Macari M.
      Type II endoleaks after endovascular repair of abdominal aortic aneurysms: natural history.
      2005Transarterial embolisation21N.S.N.S.02Resolution and sac enlargement
      Tutein
      • Tutein Nolthenius R.P.
      • Van Herwaarden J.A.
      • Van den Berg J.C.
      • Van Marrewijk C.
      • Teijink J.A.W.
      • Moll F.L.
      Three year single centre experience with the AneuRx aortic stent graft.
      2001Translumbar/transarterial embolisation44N.S.N.S.N.S.4Resolution
      Van Bindsbergen
      • Van Bindsbergen L.
      • Braak S.J.
      • Van Strijen M.J.L.
      • De Vries J.P.P.M.
      Type II endoleak embolization after endovascular abdominal aortic aneurysm repair with use of real-time three-dimensional fluoroscopic needle guidance.
      2010Translumbar embolisation55N.S.N.S.N.S.5Resolution
      Van Lammeren
      • Van Lammeren G.W.
      • Fioole B.
      • Waasdorp E.J.
      • Moll F.L.
      • Van Herwaarden J.A.
      • De Vries J.P.P.M.
      Long-term follow-up of secondary interventions after endovascular aneurysm repair with the AneuRx endoprosthesis: a single-center experience.
      2010Transarterial embolisation87N.S.N.S.17Lack of sac enlargement
      Voute
      • Voûte M.T.
      • Bastos Gonçalves F.M.
      • Hendriks J.M.
      • Metz R.
      • Van Sambeek M.R.H.M.
      • Muhs B.E.
      • et al.
      Treatment of post-implantation aneurysm growth by laparoscopic sac fenestration: long-term results.
      2013Laparoscopic fenestration44N.S.N.S.22Lack of sac enlargement
      Walker
      • Walker J.
      • Tucker L.Y.
      • Goodney P.
      • Candell L.
      • Hua H.
      • Okuhn S.
      • et al.
      Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth.
      2015Various embolisation techniques82N.S.N.S.N.S.3732Lack of sac enlargement
      Wojtaszek
      • Wojtaszek M.
      • Wnuk E.
      • Maciag R.
      • Solonynko B.
      • Korzeniowski K.
      • Lamparski K.
      • et al.
      Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx.
      2017Transarterial embolisation2217N.S.N.S.N.S.17Resolution
      Yamada
      • Yamada M.
      • Takahashi H.
      • Tauchi Y.
      • Satoh H.
      • Matsuda H.
      Open surgical repair can Be one option for the treatment of persistent type II endoleak after EVAR.
      2015Open ligation555005Resolution and sac diameter decrease
      Yang
      • Yang R.Y.
      • Tan K.T.
      • Beecroft J.R.
      • Rajan D.K.
      • Jaskolka J.D.
      Direct sac puncture versus transarterial embolization of type II endoleaks: an evaluation and comparison of outcomes.
      2017Transarterial or direct puncture embolisation2315N.S.N.S.216Resolution
      Total107387.9 (83.1–92.1)68.4 (61.2–75.1)
      N.S. = not stated.
      Follow up after the treatment of the type II endoleak ranged between 6.0 and 46.0 months. The definition of clinical success was not homogenous, with approximately half of the studies employing a definition of resolution of the endoleak, while the other half used sac diameter stabilisation or decrease on latest follow up as the determinant of clinical success. The overall clinical success rate was 68.4% (95% CI 61.2–75.1%; I2 = 83.0%). Clinical success solely defined as resolution on follow up imaging was confirmed in 67.5% (95% CI 57.0–77.2) of patients. Because different definitions were employed for clinical success, it is worthwhile looking at changes in sac diameter separately. Among 40 studies detailing sac dynamics, decrease or stable sac, with or without resolution, was achieved in 78.4% (95% CI 70.2–85.6%; I2 = 83.4%).

      Long-term follow up and strict outcome measures

      The total number of patients followed for at least 12 months, who underwent the secondary procedure for sac growth, and for whom sac dynamics were reported as an outcome was 373 across 18 studies (Fig. 2). Median follow up across the studies in this sub-cohort was 21.5 months (12.0–45.6 months). The technical success rate after secondary intervention was 88.8% (95% CI 81.5–94.4%; I2 = 71.3%). An absence of a subsequent increase in sac diameter was reported in 83.3% of patients (95% CI 73.0–91.5%; I2 = 81.3%).
      Figure 2
      Figure 2Total number of patients followed for at least 12 months, who underwent the secondary procedure for sac growth, and for whom sac dynamics were reported as an outcome across 18 studies.
      Twenty-four months after the secondary intervention, patients treated for sac growth numbered 241 in 11 studies. In 157 of these patients details regarding sac dynamics were reported. Within this group, 83.7% (95% CI 55.6–99.0%; I2 = 91.2%) had a stable or decrease in sac diameter. An actual decrease in sac size was reported in 27 of 40 patients (62.3%; 95% CI 8.4–99.8%; I2 = 93.6%). Because of small numbers, analysis at 36 month follow up was not performed.

      Adverse outcomes of secondary intervention

      With regard to adverse clinical outcomes (Table 3), the incidence following repair was generally low. The pooled estimate of AAA related mortality following treatment of type II endoleaks of 53 studies was 1.8% (95% CI 1.1–2.7%; I2 = 0.0%). These mortality cases were distributed as follows: three after transarterial coil embolisation, two after open ligation, and one after unspecified embolisation. Peri-operative complications occurred in 3.8% (95% CI 2.7–5.2%; I2 = 2.4%) of patients, and included cardiac complications, colonic ischaemia, contrast nephropathy, and displacement of a coil between the vena cava and the aorta during an embolisation procedure. The overall re-intervention rate was 14.7% (95% CI 11.2–18.5%; I2 = 56.9%), and conversion to open repair was performed in 4.3% of patients (95% CI 2.7–6.2%; I2 = 40.6%). Secondary rupture was reported in 1.8% (95% CI 1.1–2.8%; I2 = 0.0%) of patients after treatment for type II endoleak. Among the studies describing patients with follow up greater than 12 months, the secondary intervention and conversion rate were, respectively, 14.6% (95% CI 10.5–19.3%; I2 = 58.2%) and 3.6% (95% CI 2.1–5.5%; I2 = 20.6%). Rupture occurred in 1.5% of patients (95% CI 0.7–2.5%; I2 = 0.0%). A total of six aneurysm related deaths occurred, of which four were attributed to late secondary rupture. One death occurred because of colonic ischaemia after an open ligation procedure. The final patient died during explantation of the graft, which was performed because of an aorto-duodenal fistula.
      Table 3Adverse outcomes after Type 2 endoleak treatment.
      StudyYearMethod of treatmentNo. of patientsSerious complicationsRe-re-interventionConversionRuptureAAA related mortality
      Arko
      • Arko F.R.
      • Filis K.A.
      • Siedel S.A.
      • Johnson B.L.
      • Drake A.R.
      • Fogarty T.J.
      • et al.
      Intrasac flow velocities predict sealing of type II endoleaks after endovascular abdominal aortic aneurysm repair.
      2003Transarterial embolisation601000
      Aziz
      • Aziz A.
      • Menias C.O.
      • Sanchez L.A.
      • Picus D.
      • Saad N.
      • Rubin B.G.
      • et al.
      Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion.
      2012Translumbar/transarterial embolisation42116000
      Baum
      • Baum R.A.
      • Carpenter J.P.
      • Golden M.A.
      • Velazquez O.C.
      • Clark T.W.I.
      • Stavropoulous S.W.
      • et al.
      Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.
      2002Transarterial embolisation2009000
      Baum
      • Baum R.A.
      • Carpenter J.P.
      • Golden M.A.
      • Velazquez O.C.
      • Clark T.W.I.
      • Stavropoulous S.W.
      • et al.
      Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.
      2002Translumbar embolisation1300000
      Beeman
      • Beeman B.R.
      • Murtha K.
      • Doerr K.
      • McAfee-Bennett S.
      • Dougherty M.J.
      • Calligaro K.D.
      Duplex ultrasound factors predicting persistent type II endoleak and increasing AAA sac diameter after EVAR.
      2010Translumbar/transarterial embolisation/open ligation1101000
      Buckenham
      • Buckenham T.
      • McKewen M.
      • Laing A.
      • Roake J.
      • Lewis D.
      • Gordon M.K.
      Cyanoacrylate embolization of endoleaks after abdominal aortic aneurysm repair.
      2009Transarterial embolisation403000
      Carrafiello
      • Carrafiello G.
      • Ierardi A.M.
      • Radaelli A.
      • De Marchi G.
      • Floridi C.
      • Piffaretti G.
      • et al.
      Unenhanced cone beam computed tomography and fusion imaging in direct percutaneous sac injection for treatment of type II endoleak: technical note.
      2016Translumbar embolisation800000
      Chikazawa
      • Chikazawa G.
      • Hiraoka A.
      • Hirai Y.
      • Tamura K.
      • Totsugawa T.
      • Ishida A.
      • et al.
      Open reintervention for aneurysmal sac enlargement after EVAR.
      2014Open ligation700000
      Cho
      • Cho J.S.
      • Dillavou E.D.
      • Rhee R.Y.
      • Makaroun M.S.
      Late abdominal aortic aneurysm enlargement after endovascular repair with the excluder device.
      2004Transarterial embolisation200100
      Cieri
      • Cieri E.
      • De Rango P.
      • Isernia G.
      • Simonte G.
      • Ciucci A.
      • Parlani G.
      • et al.
      Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair.
      2014Various embolisation techniques520152100
      Coppi
      • Coppi G.
      • Saitta G.
      • Coppi G.
      • Gennai S.
      • Lauricella A.
      • Silingardi R.
      Transealing: a novel and simple technique for embolization of type 2 endoleaks through direct sac access from the distal stent-graft landing zone.
      2014Transarterial technique1712100
      Dobes
      • Dobes D.
      • Hajek M.
      • Raupach J.
      • Belobradek Z.
      • Kuriakose J.
      • Arestis N.
      Surgical treatment of the progressive endoleak type II after EVAR.
      2016Open ligation1040000
      El Batti
      • El Batti S.
      • Cochennec F.
      • Roudot-Thoraval F.
      • Becquemin J.P.
      Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition.
      2013Transarterial embolisation31N.S.N.S.N.S.N.S.N.S.
      Faries
      • Faries P.L.
      • Cadot H.
      • Agarwal G.
      • Kent K.C.
      • Hollier L.H.
      • Marin M.L.
      Management of endoleak after endovascular aneurysm repair: cuffs, coils, and conversion.
      2003Transarterial embolisation16N.S.2N.S.N.S.N.S.
      Ford
      • Ford C.A.
      • Lange B.B.
      • Morris C.S.
      Transcatheter embolization of abdominal aortic endograft endoleaks using onyx and coils: midterm imaging follow-up.
      2017Transarterial/CT/fluoroscopic-guided embolisation1414100
      Fujimura
      • Fujimura N.
      • Obara H.
      • Matsubara K.
      • Watada S.
      • Shibutani S.
      • Akiyoshi T.
      • et al.
      Characteristics and risk factors for type 2 endoleak in an east asian population from a Japanese multicenter database.
      2015Transarterial embolisation1101042
      Funaki
      • Funaki B.
      • Birouti N.
      • Zangan S.M.
      • Van Ha T.G.
      • Lorenz J.M.
      • Navuluri R.
      • et al.
      Evaluation and treatment of suspected type II endoleaks in patients with enlarging abdominal aortic aneurysms.
      2012Transarterial embolisation1600000
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Transarterial embolisation11N.S.2000
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Translumbar embolisation17N.S.4200
      Gallagher
      • Gallagher K.A.
      • Ravin R.A.
      • Meltzer A.J.
      • Khan A.
      • Coleman D.M.
      • Graham A.R.
      • et al.
      Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
      2012Laparoscopic clipping1N.S.0100
      Gandini
      • Gandini R.
      • Chiocchi M.
      • Loreni G.
      • Del Giudice C.
      • Morosetti D.
      • Chiaravalloti A.
      • et al.
      Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.
      2014Nonselective transcaval embolisation904010
      Gandini
      • Gandini R.
      • Chiocchi M.
      • Loreni G.
      • Del Giudice C.
      • Morosetti D.
      • Chiaravalloti A.
      • et al.
      Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.
      2014Selective transcaval embolisation2000000
      Giles
      • Giles K.A.
      • Fillinger M.F.
      • De Martino R.R.
      • Hoel A.W.
      • Powell R.J.
      • Walsh D.B.
      Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair.
      2015Transcaval embolisation2605000
      Goerich
      • Görich J.
      • Rilinger N.
      • Sokiranski R.
      • Krämer S.
      • Schütz A.
      • Sunder-Plassmann L.
      • et al.
      Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric artery approach.
      2000Transarterial embolisation1100000
      Haq
      • Haq I.U.
      • Kelay A.
      • Davis M.
      • Brookes J.
      • Mastracci T.M.
      • Constantinou J.
      Ten-year single-centre experience with type II endoleaks: intervention versus observation.
      2017Transarterial embolisation1800000
      Haq
      • Haq I.U.
      • Kelay A.
      • Davis M.
      • Brookes J.
      • Mastracci T.M.
      • Constantinou J.
      Ten-year single-centre experience with type II endoleaks: intervention versus observation.
      2017Translumbar embolisation1704000
      Haulon
      • Haulon S.
      • Tyazi A.
      • Willoteaux S.
      • Koussa M.
      • Lions C.
      • Beregi J.P.
      Embolization of type II endoleaks after aortic stent-graft implantation: technique and immediate results.
      2001Superselective catheterisation1102000
      Higashiura
      • Higashiura W.
      • Greenberg R.K.
      • Katz E.
      • Geiger L.
      • Bathurst S.
      Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms.
      2007Transarterial embolisation1100000
      Hongo
      • Hongo N.
      • Kiyosue H.
      • Shuto R.
      • Kamei N.
      • Miyamoto S.
      • Tanoue S.
      • et al.
      Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair.
      2014Transarterial embolisation2001100
      Ishibashi
      • Ishibashi H.
      • Ishiguchi T.
      • Ohta T.
      • Sugimoto I.
      • Iwata H.
      • Yamada T.
      • et al.
      Late events and mid-term results after endovascular aneurysm repair.
      2014Transarterial embolisation3N.S.100N.S.
      Jones
      • Jones J.E.
      • Atkins M.D.
      • Brewster D.C.
      • Chung T.K.
      • Kwolek C.J.
      • LaMuraglia G.M.
      • et al.
      Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.
      2007Translumbar/transarterial/open ligation16N.S.N.S.21N.S.
      Kasirajan
      • Kasirajan K.
      • Matteson B.
      • Marek J.M.
      • Langsfeld M.
      Technique and results of transfemoral superselective coil embolization of type II lumbar endoleak.
      2003Superselective catheterisation811000
      Kim
      • Kim M.H.
      • Park H.S.
      • Ahn S.
      • Min S.I.
      • Min S.K.
      • Ha J.
      • et al.
      Chronological change of the sac after endovascular aneurysm repair.
      2016Transarterial embolisation1606000
      Kumar
      • Kumar L.
      • Cowled P.
      • Boult M.
      • Howell S.
      • Fitridge R.
      Type II endoleak after endovascular aneurysm repair: natural history and treatment outcomes.
      2017Various embolisation techniques1601011
      Liewald
      • Liewald F.
      • Ermis C.
      • Görich J.
      • Halter G.
      • Scharrer-Pamler R.
      • Sunder-Plassmann L.
      Influence of treatment of type II leaks on the aneurysm surface area.
      2001Transarterial embolisation140N.S.000
      Maitrias
      • Maitrias P.
      • Kaladji A.
      • Plissonnier D.
      • Amiot S.
      • Sabatier J.
      • Coggia M.
      • et al.
      Treatment of sac expansion after endovascular aneurysm repair with obliterating endoaneurysmorrhaphy and stent graft preservation.
      2016Open ligation1020000
      Maitrias
      • Maitrias P.
      • Belhomme D.
      • Molin V.
      • Reix T.
      Obliterative endoaneurysmorrhaphy with stent graft preservation for treatment of type II progressive endoleak.
      2016Open ligation2160101
      Mansueto
      • Mansueto G.
      • Cenzi D.
      • Scuro A.
      • Gottin L.
      • Griso A.
      • Gumbs A.A.
      • et al.
      Treatment of type II endoleak with a transcatheter transcaval approach: results at 1-year follow-up.
      2007Transcatheter transcaval embolisation1201000
      Marcelin
      • Marcelin C.
      • Le Bras Y.
      • Petitpierre F.
      • Midy D.
      • Ducasse E.
      • Grenier N.
      • et al.
      Safety and efficacy of embolization using Onyx® of persistent type II endoleaks after abdominal endovascular aneurysm repair.
      2017Transarterial embolisation/Direct puncture embolisation2806000
      Martin
      • Martin M.L.
      • Dolmatch B.L.
      • Fry P.D.
      • Machan L.S.
      Treatment of type II endoleaks with Onyx.
      2001Transarterial embolisation400000
      Moulakakis
      • Moulakakis K.G.
      • Klonaris C.
      • Kakisis J.
      • Antonopoulos C.N.
      • Lazaris A.
      • Sfyroeras G.S.
      • et al.
      Treatment of type II endoleak and aneurysm expansion after EVAR.
      2017Transarterial/translumbar embolisation1003000
      Moulakakis
      • Moulakakis K.G.
      • Klonaris C.
      • Kakisis J.
      • Antonopoulos C.N.
      • Lazaris A.
      • Sfyroeras G.S.
      • et al.
      Treatment of type II endoleak and aneurysm expansion after EVAR.
      2017Open ligation1930101
      Müller-Wille
      • Müller-Wille R.
      • Wohlgemuth W.A.
      • Heiss P.
      • Wiggermann P.
      • Güntner O.
      • Schreyer A.G.
      • et al.
      Transarterial embolization of type II endoleaks after EVAR: the role of ethylene vinyl alcohol copolymer (Onyx).
      2013Transarterial embolisation1100000
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Transarterial embolisation1003000
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Translumbar embolisation301000
      Nevala
      • Nevala T.
      • Biancari F.
      • Manninen H.
      • Aho P.S.
      • Matsi P.
      • Mäkinen K.
      • et al.
      Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.
      2010Transabdominal embolisation100000
      Parry
      • Parry D.J.
      • Kessel D.O.
      • Robertson I.
      • Denton L.
      • Patel J.V.
      • Berridge D.C.
      • et al.
      Type II endoleaks: predictable, preventable, and sometimes treatable?.
      2002Transarterial embolisation601000
      Piffaretti
      • Piffaretti G.
      • Franchin M.
      • Botteri E.
      • Boni L.
      • Carrafiello G.
      • Battaglia G.
      • et al.
      Operative treatment of type 2 endoleaks involving the inferior mesenteric artery.
      2017Laparoscopic ligation1102100
      Piffaretti
      • Piffaretti G.
      • Franchin M.
      • Botteri E.
      • Boni L.
      • Carrafiello G.
      • Battaglia G.
      • et al.
      Operative treatment of type 2 endoleaks involving the inferior mesenteric artery.
      2017Transarterial embolisation1003200
      Quinones
      • Quinones-Baldrich W.
      • Levin E.S.
      • Lew W.
      • Barleben A.
      Intraprocedural and postprocedural perigraft arterial sac embolization (PASE) for endoleak treatment.
      2014Perigraft arterial embolisation100000
      Rayt
      • Rayt H.S.
      • Sandford R.M.
      • Salem M.
      • Bown M.J.
      • London N.J.
      • Sayers R.D.
      Conservative management of type 2 endoleaks is not associated with increased risk of aneurysm rupture.
      2009Various embolisation techniques101000
      Rial
      • Rial R.
      • Serrano F.J.
      • Vega M.
      • Rodriguez R.
      • Martin A.
      • Mendez J.
      • et al.
      Treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysms: translumbar puncture and injection of thrombin into the aneurysm sac.
      2004Translumbar embolisation30N.S.N.S.N.S.0
      Ribe
      • Ribe L.
      • Bicknell C.D.
      • Gibbs R.G.
      • Burfitt N.
      • Jenkins M.P.
      • Cheshire N.
      • et al.
      Long-term results of intra-arterial onyx injection for type II endoleaks following endovascular aneurysm repair.
      2017Transarterial embolisation1801000
      Richardson
      • Richardson W.S.
      • Sternbergh Iii, W.C.
      • Money S.R.
      Laparoscopic inferior mesenteric artery ligation: an alternative for the treatment of type II endoleaks.
      2003Transart. embolisation or laparoscopic ligation401000
      Sarac
      • Sarac T.P.
      • Gibbons C.
      • Vargas L.
      • Liu J.
      • Srivastava S.
      • Bena J.
      • et al.
      Long-term follow-up of type II endoleak embolization reveals the need for close surveillance.
      2012Various embolisation techniques95819800
      Scali
      • Scali S.T.
      • Vlada A.
      • Chang C.K.
      • Beck A.W.
      Transcaval embolization as an alternative technique for the treatment of type II endoleak after endovascular aortic aneurysm repair.
      2013Transcaval embolisation601000
      Silverberg
      • Silverberg D.
      • Baril D.T.
      • Ellozy S.H.
      • Carroccio A.
      • Greyrose S.E.
      • Lookstein R.A.
      • et al.
      An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach.
      2006Transfemoral/translumbar embolisation19N.S.000N.S.
      Stavropoulos
      • Stavropoulos S.W.
      • Park J.
      • Fairman R.
      • Carpenter J.
      Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization.
      2009Translumbar embolisation62210000
      Stavropoulos
      • Stavropoulos S.W.
      • Park J.
      • Fairman R.
      • Carpenter J.
      Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization.
      2009Modified transarterial embolisation2303000
      Steinmetz
      • Steinmetz E.
      • Rubin B.G.
      • Sanchez L.A.
      • Choi E.T.
      • Geraghty P.J.
      • Baty J.
      • et al.
      Type II endoleak after endovascular abdominal aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective.
      2004Translumbar/transarterial embolisation500000
      Tolia
      • Tolia A.J.
      • Landis R.
      • Lamparello P.
      • Rosen R.
      • Macari M.
      Type II endoleaks after endovascular repair of abdominal aortic aneurysms: natural history.
      2005Transarterial embolisation200000
      Tutein
      • Tutein Nolthenius R.P.
      • Van Herwaarden J.A.
      • Van den Berg J.C.
      • Van Marrewijk C.
      • Teijink J.A.W.
      • Moll F.L.
      Three year single centre experience with the AneuRx aortic stent graft.
      2001Translumbar/transarterial embolisation400000
      Van Bindsbergen
      • Van Bindsbergen L.
      • Braak S.J.
      • Van Strijen M.J.L.
      • De Vries J.P.P.M.
      Type II endoleak embolization after endovascular abdominal aortic aneurysm repair with use of real-time three-dimensional fluoroscopic needle guidance.
      2010Translumbar embolisation500000
      Van Lammeren
      • Van Lammeren G.W.
      • Fioole B.
      • Waasdorp E.J.
      • Moll F.L.
      • Van Herwaarden J.A.
      • De Vries J.P.P.M.
      Long-term follow-up of secondary interventions after endovascular aneurysm repair with the AneuRx endoprosthesis: a single-center experience.
      2010Transarterial embolisation800011
      Voute
      • Voûte M.T.
      • Bastos Gonçalves F.M.
      • Hendriks J.M.
      • Metz R.
      • Van Sambeek M.R.H.M.
      • Muhs B.E.
      • et al.
      Treatment of post-implantation aneurysm growth by laparoscopic sac fenestration: long-term results.
      2013Laparoscopic fenestration402200
      Walker
      • Walker J.
      • Tucker L.Y.
      • Goodney P.
      • Candell L.
      • Hua H.
      • Okuhn S.
      • et al.
      Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth.
      2015Various embolisation techniques82N.S.N.S.N.S.N.S.N.S.
      Wojtaszek
      • Wojtaszek M.
      • Wnuk E.
      • Maciag R.
      • Solonynko B.
      • Korzeniowski K.
      • Lamparski K.
      • et al.
      Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx.
      2017Transarterial embolisation2203000
      Yamada
      • Yamada M.
      • Takahashi H.
      • Tauchi Y.
      • Satoh H.
      • Matsuda H.
      Open surgical repair can Be one option for the treatment of persistent type II endoleak after EVAR.
      2015Open ligation500000
      Yang
      • Yang R.Y.
      • Tan K.T.
      • Beecroft J.R.
      • Rajan D.K.
      • Jaskolka J.D.
      Direct sac puncture versus transarterial embolization of type II endoleaks: an evaluation and comparison of outcomes.
      2017Transarterial or direct puncture embolisation2318000
      Total10733.8 (2.7–5.2)14.7 (11.2–18.5)4.3 (2.7–6.2)1.8 (1.1–2.8)1.8 (1.1–2.7)
      N.S. = not stated.

      Discussion

      The present study has demonstrated that although the technical success rate of type II endoleak treatment is high, ranging from 84% to 100% depending on the technique, one third failed to either completely resolve or show signs of sac diameter stabilisation or decrease at the latest follow up. In addition, the rate of rupture after intervention for type II endoleak was less than 2% in studies reporting at least 12 months of follow up, which does not appear to be different from EVAR studies in general.
      • Schermerhorn M.L.
      • O'Malley A.J.
      • Jhaveri A.
      • Cotterill P.
      • Pomposelli F.
      • Landon B.E.
      Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population.
      The relevance of type II endoleaks has been a matter of debate for many years and was thoroughly investigated in a recent systematic review by Sidloff et al.
      • Sidloff D.A.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak after endovascular aneurysm repair.
      However, this review did not specifically evaluate the outcome of treatment, as no distinction was made for the definition of successful treatment.
      • Sidloff D.A.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak after endovascular aneurysm repair.
      Moreover, only a very limited number of patients undergoing intervention were included in this study, particularly considering that no criteria were set for minimum follow up time. Although the clinical success rate in this review indicates reasonable outcomes, it has been shown before that the efficacy of type II endoleak treatment in terms of the prevention of sac growth deteriorates over time, with a rapid decrease one year post embolisation.
      • Sarac T.P.
      • Gibbons C.
      • Vargas L.
      • Liu J.
      • Srivastava S.
      • Bena J.
      • et al.
      Long-term follow-up of type II endoleak embolization reveals the need for close surveillance.
      This supports the complexity and multifactorial aetiology of type II endoleaks as described by Solis et al., and indicates that it is likely there are multiple sources of in- and outflow of the aneurysmal sac.
      • Solis M.M.
      • Ayerdi J.
      • Babcock G.A.
      • Parra J.R.
      • McLafferty R.B.
      • Gruneiro L.A.
      • et al.
      Mechanism of failure in the treatment of type II endoleak with percutaneous coil embolization.
      Additionally, when reviewing the included articles, it became apparent that multiple definitions of clinical success were in use. While the current consensus on the purpose of treating type II endoleaks is eliminating persistent aneurysm sac growth, thereby diminishing the risk of secondary rupture, studies often consider only lack of radiological evidence of arterial backflow into the aneurysm sac as the primary endpoint.
      • Mees B.
      • Voute M.
      • Bastos Goncalves F.
      • Mota Capitao L.
      • Verhagen H.
      Intervention for type II endoleaks? "Primum non nocere": appraisal for the conservative management of low-pressure endoleaks after endovascular aneurysm repair.
      • Cieri E.
      • De Rango P.
      • Isernia G.
      • Simonte G.
      • Ciucci A.
      • Parlani G.
      • et al.
      Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair.
      However, there is evidence that not all patent (nor persistent) type II endoleaks are associated with sac growth.
      • Darling 3rd, R.C.
      • Ozsvath K.
      • Chang B.B.
      • Kreienberg P.B.
      • Paty P.S.
      • Lloyd W.E.
      • et al.
      The incidence, natural history, and outcome of secondary intervention for persistent collateral flow in the excluded abdominal aortic aneurysm.
      • Silverberg D.
      • Baril D.T.
      • Ellozy S.H.
      • Carroccio A.
      • Greyrose S.E.
      • Lookstein R.A.
      • et al.
      An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach.
      • Tolia A.J.
      • Landis R.
      • Lamparello P.
      • Rosen R.
      • Macari M.
      Type II endoleaks after endovascular repair of abdominal aortic aneurysms: natural history.
      • Parent F.N.
      • Meier G.H.
      • Godziachvili V.
      • LeSar C.J.
      • Parker F.M.
      • Carter K.A.
      • et al.
      The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan.
      Moreover, multiple studies, including a recent meta-analysis, demonstrated that with both contrast CT, as well as contrast enhanced ultrasound, a substantial number of type II endoleaks may still be missed on follow up imaging.
      • Parent F.N.
      • Meier G.H.
      • Godziachvili V.
      • LeSar C.J.
      • Parker F.M.
      • Carter K.A.
      • et al.
      The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan.
      • Haulon S.
      • Lions C.
      • McFadden E.P.
      • Koussa M.
      • Gaxotte V.
      • Halna P.
      • et al.
      Prospective evaluation of magnetic resonance imaging after endovascular treatment of infrarenal aortic aneurysms.
      • van der Laan M.J.
      • Bartels L.W.
      • Viergever M.A.
      • Blankensteijn J.D.
      Computed tomography versus magnetic resonance imaging of endoleaks after EVAR.
      • McLafferty R.B.
      • McCrary B.S.
      • Mattos M.A.
      • Karch L.A.
      • Ramsey D.E.
      • Solis M.M.
      • et al.
      The use of color-flow duplex scan for the detection of endoleaks.
      • D'Audiffret A.
      • Desgranges P.
      • Kobeiter D.H.
      • Becquemin J.P.
      Follow-up evaluation of endoluminally treated abdominal aortic aneurysms with duplex ultrasonography: validation with computed tomography.
      • Fillinger M.F.
      New imaging techniques in endovascular surgery.
      Also, some methods of treatment involving coils or contrast impregnated bioglue render subsequent observation of endoleaks exceedingly difficult. Furthermore, reappearance of other collaterals on follow up studies are frequently reported.
      • Sarac T.P.
      • Gibbons C.
      • Vargas L.
      • Liu J.
      • Srivastava S.
      • Bena J.
      • et al.
      Long-term follow-up of type II endoleak embolization reveals the need for close surveillance.
      • Parent F.N.
      • Meier G.H.
      • Godziachvili V.
      • LeSar C.J.
      • Parker F.M.
      • Carter K.A.
      • et al.
      The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan.
      The use of short-term type II endoleak resolution as the primary measurement of success may therefore be unreliable and should be avoided. When looking at studies with appropriate patient selection and follow up time, in addition to using sac dynamics as the endpoint for clinical success instead of resolution, the evidence is particularly scarce. In the present review, only three studies reported on decreases in sac diameter in patients experiencing initial sac growth for at least 24 months, with a combined sample of only 40 patients.
      With a cumulative peri-operative complication rate of 4%, procedural morbidity of type II endoleaks is low regardless of modality. However, one must acknowledge that these studies were mostly conducted in experienced centres and it is likely that publication bias affects reported outcomes. As a result, real world complication rates may be underestimated. Moreover, because as many as 15% of patients undergo a second or even a third procedure, these figures can amount to a significant risk during the course of treatment.
      • Sarac T.P.
      • Gibbons C.
      • Vargas L.
      • Liu J.
      • Srivastava S.
      • Bena J.
      • et al.
      Long-term follow-up of type II endoleak embolization reveals the need for close surveillance.
      Type II endoleak has been associated with an increased risk of rupture and AAA related mortality.
      • Jones J.E.
      • Atkins M.D.
      • Brewster D.C.
      • Chung T.K.
      • Kwolek C.J.
      • LaMuraglia G.M.
      • et al.
      Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.
      • Ohki T.
      • Veith F.J.
      • Shaw P.
      • Lipsitz E.
      • Suggs W.D.
      • Wain R.A.
      • et al.
      Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience.
      As prevention of type II endoleaks is not possible in most cases, the most important question is whether these interventions reduce the chances of rupture and AAA related death. From the accumulated data, the risk of secondary rupture was low, with only 2% experiencing rupture during a minimum of 12 months’ follow up after treatment of their type II endoleak. This is similar to the widely reported rupture rate after EVAR in general and compares well with rupture rates in conservatively treated patients with type II endoleak.
      • Sidloff D.A.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak after endovascular aneurysm repair.
      • Sidloff D.A.
      • Gokani V.
      • Stather P.W.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Type II endoleak: conservative management is a safe strategy.
      However, longer follow up data after re-interventions are needed to draw more reliable conclusions on the total incidence of secondary rupture. In addition, it should be noted that a retrospective comparison is difficult, particularly when comparing with conservative treatment strategies, because of confounding by indication in retrospective studies. Nevertheless, Walker et al. found that all cause and aneurysm related mortality were unaffected by type II endoleaks in a multicentre EVAR registry.
      • Walker J.
      • Tucker L.Y.
      • Goodney P.
      • Candell L.
      • Hua H.
      • Okuhn S.
      • et al.
      Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth.
      Moreover, even in the presence of sac growth, no differences were observed in aneurysm related outcomes between patients who underwent a re-intervention and those who were simply observed.
      Current ESVS guidelines advise a secondary surgical intervention when sac enlargement of more than 10 mm is detected.
      • Moll F.L.
      • Powell J.T.
      • Fraedrich G.
      • Verzini F.
      • Haulon S.
      • Waltham M.
      • et al.
      Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery.
      In the studies reviewed, it was noted that many authors use sac enlargement of five mm or less, or even no growth as an indication for intervention. The lack of apparent clinical benefit of these interventions underlines the need for careful patient selection. Because of the relatively liberal use of current guidelines, no comment can be made on the possible advantages of intervention in the cohort solely consisting of patients with 10 mm sac growth, as recommended.
      • Moll F.L.
      • Powell J.T.
      • Fraedrich G.
      • Verzini F.
      • Haulon S.
      • Waltham M.
      • et al.
      Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery.
      In addition, studies have demonstrated that spontaneous sealing of type II endoleaks occurs frequently, even after longer periods of time.
      • Parent F.N.
      • Meier G.H.
      • Godziachvili V.
      • LeSar C.J.
      • Parker F.M.
      • Carter K.A.
      • et al.
      The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan.
      • Tuerff S.N.
      • Rockman C.B.
      • Lamparello P.J.
      • Adelman M.A.
      • Jacobowitz G.R.
      • Gagne P.J.
      • et al.
      Are type II (branch vessel) endoleaks really benign?.
      Because of this natural behavior of type II endoleaks, it remains difficult to assess the merits of secondary intervention, as it is likely that not all clinical successes should be attributed to the secondary procedure. Also, it remains difficult to assess which type II endoleaks are prone to seal in the retrospective studies in the present cohort. In light of this, it is desirable that prospective observational studies be conducted with the specific goal of following the natural course of type II endoleaks.
      In addition to a lack of prospectively gathered data, it is likely that publication bias occurred with regards to technical success of secondary intervention techniques in the current literature. The aim of a significant number of included studies was to demonstrate the usefulness of a secondary intervention. It stands to reason that these studies have a smaller chance of being published by the authors, if the demonstrated tool or technique is unsuccessful or has serious problems or shortcomings. The results of this study therefore are likely to show an overestimation of technical and clinical success. This, in combination with the scarcity of data on type II endoleak treatment despite routine use of EVAR and secondary interventions,
      • Kent K.C.
      Clinical practice. Abdominal aortic aneurysms.
      underlines the paucity of evidence supporting treatment. Yet it should also be noted that the wide inclusion of studies employing various indications for secondary interventions means that the instances when secondary interventions may actually have been warranted because of the imminent risk of secondary rupture could not be distilled from the present data. Finally, a lack of separate reporting of unsuccessful procedures means that the specific outcome after failed secondary intervention for type II endoleak unfortunately could not be investigated using these data.
      Clinicians should be aware that type II endoleak in combination with sac growth may actually be the result of an unexpected underlying type I or III endoleak as described by Aziz et al. and more recently by Madigan et al.
      • Aziz A.
      • Menias C.O.
      • Sanchez L.A.
      • Picus D.
      • Saad N.
      • Rubin B.G.
      • et al.
      Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion.
      • Madigan M.C.
      • Singh M.J.
      • Chaer R.A.
      • Al-Khoury G.
      • Makaroun M.S.
      Failure of type II endoleak treatment may be due to occult type I or III endoleaks.
      In this context, type II endoleaks may be seen as sentinel endoleaks and may warrant thorough investigation of the efficacy of the graft integrity and the proximal and distal seal. Direct endoleaks may even be intermittent, as demonstrated before, which complicates diagnosis even further.
      • Faries P.L.
      • Briggs V.L.
      • Bernheim J.
      • Kent K.C.
      • Hollier L.H.
      • Marin M.L.
      Increased recognition of type II endoleaks using a modified intraoperative angiographic protocol: implications for intermittent endoleak and aneurysm expansion.
      This systematic review has several limitations that restrict its conclusions. First, it was not always possible to differentiate between patients who had already undergone a prior secondary intervention, before the studied intervention and it was not always possible to identify patients with multiple type II endoleaks. Because these two patient groups are more likely to represent relatively complex cases, this might negatively affect treatment outcome. Also, insufficiently clear data on the recurrence of an endoleak after initial technical success precluded assessment of recurrence in those achieving post-operative resolution. Finally, the limited amount of evidence on type II endoleak treatment meant that it was not possible to perform a fair comparison of the different treatment techniques.
      In conclusion, although performed frequently, there is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR, even in patients with growing aneurysms. The currently available techniques are reported to be generally safe, causing only limited post-operative morbidity and mortality. Yet, the clinical course after intervention may not be different from conservative treatment. Despite their safety, there are virtually no prospective studies comparing intervention with observation, and only three retrospective studies with a combined volume of only 40 patients reported on decreases in sac diameter with sufficient follow up in a group of patients experiencing initial sac growth. Among these, an actual decrease in sac diameter was only observed in 27 patients. The lack of data supporting its efficacy, together with the multifactorial cause of sac growth after EVAR, leads to difficulty in assessing the merits of secondary intervention for type II endoleak with regards to reducing the risk of aneurysm rupture.

      Conflict of interest

      None.

      Funding

      None.

      Appendix A. Supplementary data

      The following are the supplementary data related to this article:

      References

        • Schermerhorn M.L.
        • O'Malley A.J.
        • Jhaveri A.
        • Cotterill P.
        • Pomposelli F.
        • Landon B.E.
        Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population.
        N Engl J Med. 2008; 358: 464-474
        • Prinssen M.
        • Verhoeven E.L.
        • Buth J.
        • Cuypers P.W.
        • van Sambeek M.R.
        • Balm R.
        • et al.
        A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.
        N Engl J Med. 2004; 351: 1607-1618
        • Lederle F.A.
        • Freischlag J.A.
        • Kyriakides T.C.
        • Padberg Jr., F.T.
        • Matsumura J.S.
        • Kohler T.R.
        • et al.
        Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.
        JAMA. 2009; 302: 1535-1542
        • Greenhalgh R.M.
        • Brown L.C.
        • Kwong G.P.
        • Powell J.T.
        • Thompson S.G.
        • Participants Et
        Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial.
        Lancet. 2004; 364: 843-848
        • Kent K.C.
        Clinical practice. Abdominal aortic aneurysms.
        N Engl J Med. 2014; 371: 2101-2108
        • Parodi J.C.
        • Palmaz J.C.
        • Barone H.D.
        Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.
        Ann Vasc Surg. 1991; 5: 491-499
        • Schermerhorn M.L.
        • Bensley R.P.
        • Giles K.A.
        • Hurks R.
        • O'Malley A.J.
        • Cotterill P.
        • et al.
        Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995–2008: a retrospective observational study.
        Ann Surg. 2012; 256: 651-658
        • Chadi S.A.
        • Rowe B.W.
        • Vogt K.N.
        • Novick T.V.
        • Harris J.R.
        • Derose G.
        • et al.
        Trends in management of abdominal aortic aneurysms.
        J Vasc Surg. 2012; 55: 924-928
        • Lederle F.A.
        • Freischlag J.A.
        • Kyriakides T.C.
        • Matsumura J.S.
        • Padberg Jr., F.T.
        • Kohler T.R.
        • et al.
        Long-term comparison of endovascular and open repair of abdominal aortic aneurysm.
        N Engl J Med. 2012; 367: 1988-1997
        • Patel R.
        • Sweeting M.J.
        • Powell J.T.
        • Greenhalgh R.M.
        • Investigators Et
        Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial.
        Lancet. 2016; 388: 2366-2374
        • Schermerhorn M.L.
        • Buck D.B.
        • O'Malley A.J.
        • Curran T.
        • McCallum J.C.
        • Darling J.
        • et al.
        Long-term outcomes of abdominal aortic aneurysm in the medicare population.
        N Engl J Med. 2015; 373: 328-338
        • Gelfand D.V.
        • White G.H.
        • Wilson S.E.
        Clinical significance of type II endoleak after endovascular repair of abdominal aortic aneurysm.
        Ann Vasc Surg. 2006; 20: 69-74
        • Choke E.
        • Thompson M.
        Endoleak after endovascular aneurysm repair: current concepts.
        J Cardiovasc Surg (Torino). 2004; 45: 349-366
        • Sidloff D.A.
        • Stather P.W.
        • Choke E.
        • Bown M.J.
        • Sayers R.D.
        Type II endoleak after endovascular aneurysm repair.
        Br J Surg. 2013; 100: 1262-1270
        • Moll F.L.
        • Powell J.T.
        • Fraedrich G.
        • Verzini F.
        • Haulon S.
        • Waltham M.
        • et al.
        Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery.
        Eur J Vasc Endovasc Surg. 2011; 41: S1-S58
        • Chaikof E.L.
        • Brewster D.C.
        • Dalman R.L.
        • Makaroun M.S.
        • Illig K.A.
        • Sicard G.A.
        • et al.
        SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary.
        J Vasc Surg. 2009; 50: 880-896
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • Sarac T.P.
        • Gibbons C.
        • Vargas L.
        • Liu J.
        • Srivastava S.
        • Bena J.
        • et al.
        Long-term follow-up of type II endoleak embolization reveals the need for close surveillance.
        J Vasc Surg. 2012; 55: 33-40
        • Solis M.M.
        • Ayerdi J.
        • Babcock G.A.
        • Parra J.R.
        • McLafferty R.B.
        • Gruneiro L.A.
        • et al.
        Mechanism of failure in the treatment of type II endoleak with percutaneous coil embolization.
        J Vasc Surg. 2002; 36: 485-491
        • Mees B.
        • Voute M.
        • Bastos Goncalves F.
        • Mota Capitao L.
        • Verhagen H.
        Intervention for type II endoleaks? "Primum non nocere": appraisal for the conservative management of low-pressure endoleaks after endovascular aneurysm repair.
        J Cardiovasc Surg (Torino). 2013; 54: 477-484
        • Cieri E.
        • De Rango P.
        • Isernia G.
        • Simonte G.
        • Ciucci A.
        • Parlani G.
        • et al.
        Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair.
        J Vasc Surg. 2014; 59: 930-937
        • Darling 3rd, R.C.
        • Ozsvath K.
        • Chang B.B.
        • Kreienberg P.B.
        • Paty P.S.
        • Lloyd W.E.
        • et al.
        The incidence, natural history, and outcome of secondary intervention for persistent collateral flow in the excluded abdominal aortic aneurysm.
        J Vasc Surg. 1999; 30: 968-976
        • Silverberg D.
        • Baril D.T.
        • Ellozy S.H.
        • Carroccio A.
        • Greyrose S.E.
        • Lookstein R.A.
        • et al.
        An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach.
        J Vasc Surg. 2006; 44: 453-459
        • Tolia A.J.
        • Landis R.
        • Lamparello P.
        • Rosen R.
        • Macari M.
        Type II endoleaks after endovascular repair of abdominal aortic aneurysms: natural history.
        Radiology. 2005; 235: 683-686
        • Parent F.N.
        • Meier G.H.
        • Godziachvili V.
        • LeSar C.J.
        • Parker F.M.
        • Carter K.A.
        • et al.
        The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan.
        J Vasc Surg. 2002; 35: 474-481
        • Haulon S.
        • Lions C.
        • McFadden E.P.
        • Koussa M.
        • Gaxotte V.
        • Halna P.
        • et al.
        Prospective evaluation of magnetic resonance imaging after endovascular treatment of infrarenal aortic aneurysms.
        Eur J Vasc Endovasc Surg. 2001; 22: 62-69
        • van der Laan M.J.
        • Bartels L.W.
        • Viergever M.A.
        • Blankensteijn J.D.
        Computed tomography versus magnetic resonance imaging of endoleaks after EVAR.
        Eur J Vasc Endovasc Surg. 2006; 32: 361-365
        • McLafferty R.B.
        • McCrary B.S.
        • Mattos M.A.
        • Karch L.A.
        • Ramsey D.E.
        • Solis M.M.
        • et al.
        The use of color-flow duplex scan for the detection of endoleaks.
        J Vasc Surg. 2002; 36: 100-104
        • D'Audiffret A.
        • Desgranges P.
        • Kobeiter D.H.
        • Becquemin J.P.
        Follow-up evaluation of endoluminally treated abdominal aortic aneurysms with duplex ultrasonography: validation with computed tomography.
        J Vasc Surg. 2001; 33: 42-50
        • Fillinger M.F.
        New imaging techniques in endovascular surgery.
        Surg Clin North Am. 1999; 79: 451-475
        • Jones J.E.
        • Atkins M.D.
        • Brewster D.C.
        • Chung T.K.
        • Kwolek C.J.
        • LaMuraglia G.M.
        • et al.
        Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.
        J Vasc Surg. 2007; 46: 1-8
        • Ohki T.
        • Veith F.J.
        • Shaw P.
        • Lipsitz E.
        • Suggs W.D.
        • Wain R.A.
        • et al.
        Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience.
        Ann Surg. 2001; 234: 323-335
        • Sidloff D.A.
        • Gokani V.
        • Stather P.W.
        • Choke E.
        • Bown M.J.
        • Sayers R.D.
        Type II endoleak: conservative management is a safe strategy.
        Eur J Vasc Endovasc Surg. 2014; 48: 391-399
        • Walker J.
        • Tucker L.Y.
        • Goodney P.
        • Candell L.
        • Hua H.
        • Okuhn S.
        • et al.
        Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth.
        J Vasc Surg. 2015; 62: 551-561
        • Tuerff S.N.
        • Rockman C.B.
        • Lamparello P.J.
        • Adelman M.A.
        • Jacobowitz G.R.
        • Gagne P.J.
        • et al.
        Are type II (branch vessel) endoleaks really benign?.
        Ann Vasc Surg. 2002; 16: 50-54
        • Aziz A.
        • Menias C.O.
        • Sanchez L.A.
        • Picus D.
        • Saad N.
        • Rubin B.G.
        • et al.
        Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion.
        J Vasc Surg. 2012; 55: 1263-1267
        • Madigan M.C.
        • Singh M.J.
        • Chaer R.A.
        • Al-Khoury G.
        • Makaroun M.S.
        Failure of type II endoleak treatment may be due to occult type I or III endoleaks.
        J Vasc Surg. 2016; 63: 9S
        • Faries P.L.
        • Briggs V.L.
        • Bernheim J.
        • Kent K.C.
        • Hollier L.H.
        • Marin M.L.
        Increased recognition of type II endoleaks using a modified intraoperative angiographic protocol: implications for intermittent endoleak and aneurysm expansion.
        Ann Vasc Surg. 2003; 17: 608-614
        • Arko F.R.
        • Filis K.A.
        • Siedel S.A.
        • Johnson B.L.
        • Drake A.R.
        • Fogarty T.J.
        • et al.
        Intrasac flow velocities predict sealing of type II endoleaks after endovascular abdominal aortic aneurysm repair.
        J Vasc Surg. 2003; 37: 8-15
        • Baum R.A.
        • Carpenter J.P.
        • Golden M.A.
        • Velazquez O.C.
        • Clark T.W.I.
        • Stavropoulous S.W.
        • et al.
        Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.
        J Vasc Surg. 2002; 35: 23-29
        • Beeman B.R.
        • Murtha K.
        • Doerr K.
        • McAfee-Bennett S.
        • Dougherty M.J.
        • Calligaro K.D.
        Duplex ultrasound factors predicting persistent type II endoleak and increasing AAA sac diameter after EVAR.
        J Vasc Surg. 2010; 52: 1147-1152
        • Buckenham T.
        • McKewen M.
        • Laing A.
        • Roake J.
        • Lewis D.
        • Gordon M.K.
        Cyanoacrylate embolization of endoleaks after abdominal aortic aneurysm repair.
        ANZ J Surg. 2009; 79: 841-843
        • Carrafiello G.
        • Ierardi A.M.
        • Radaelli A.
        • De Marchi G.
        • Floridi C.
        • Piffaretti G.
        • et al.
        Unenhanced cone beam computed tomography and fusion imaging in direct percutaneous sac injection for treatment of type II endoleak: technical note.
        Cardiovasc Intervent Radiol. 2016; 39: 447-452
        • Chikazawa G.
        • Hiraoka A.
        • Hirai Y.
        • Tamura K.
        • Totsugawa T.
        • Ishida A.
        • et al.
        Open reintervention for aneurysmal sac enlargement after EVAR.
        Ann Vasc Dis. 2014; 7: 350-353
        • Cho J.S.
        • Dillavou E.D.
        • Rhee R.Y.
        • Makaroun M.S.
        Late abdominal aortic aneurysm enlargement after endovascular repair with the excluder device.
        J Vasc Surg. 2004; 39: 1236-1241
        • Coppi G.
        • Saitta G.
        • Coppi G.
        • Gennai S.
        • Lauricella A.
        • Silingardi R.
        Transealing: a novel and simple technique for embolization of type 2 endoleaks through direct sac access from the distal stent-graft landing zone.
        Eur J Vasc Endovasc Surg. 2014; 47: 394-401
        • Dobes D.
        • Hajek M.
        • Raupach J.
        • Belobradek Z.
        • Kuriakose J.
        • Arestis N.
        Surgical treatment of the progressive endoleak type II after EVAR.
        Eur Surg Acta Chir Austriaca. 2016; 48: 141-143
        • El Batti S.
        • Cochennec F.
        • Roudot-Thoraval F.
        • Becquemin J.P.
        Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition.
        J Vasc Surg. 2013; 57: 1291-1298
        • Faries P.L.
        • Cadot H.
        • Agarwal G.
        • Kent K.C.
        • Hollier L.H.
        • Marin M.L.
        Management of endoleak after endovascular aneurysm repair: cuffs, coils, and conversion.
        J Vasc Surg. 2003; 37: 1155-1161
        • Ford C.A.
        • Lange B.B.
        • Morris C.S.
        Transcatheter embolization of abdominal aortic endograft endoleaks using onyx and coils: midterm imaging follow-up.
        J Vasc Diagn Interv. 2017; 5: 15-19
        • Fujimura N.
        • Obara H.
        • Matsubara K.
        • Watada S.
        • Shibutani S.
        • Akiyoshi T.
        • et al.
        Characteristics and risk factors for type 2 endoleak in an east asian population from a Japanese multicenter database.
        Circ J. 2015; 80: 118-123
        • Funaki B.
        • Birouti N.
        • Zangan S.M.
        • Van Ha T.G.
        • Lorenz J.M.
        • Navuluri R.
        • et al.
        Evaluation and treatment of suspected type II endoleaks in patients with enlarging abdominal aortic aneurysms.
        J Vasc Intervent Radiol. 2012; 23: 866-872
        • Gallagher K.A.
        • Ravin R.A.
        • Meltzer A.J.
        • Khan A.
        • Coleman D.M.
        • Graham A.R.
        • et al.
        Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.
        J Endovasc Ther. 2012; 19: 182-192
        • Gandini R.
        • Chiocchi M.
        • Loreni G.
        • Del Giudice C.
        • Morosetti D.
        • Chiaravalloti A.
        • et al.
        Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.
        J Endovasc Ther. 2014; 21: 714-722
        • Giles K.A.
        • Fillinger M.F.
        • De Martino R.R.
        • Hoel A.W.
        • Powell R.J.
        • Walsh D.B.
        Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair.
        J Vasc Surg. 2015; 61: 1129-1136
        • Görich J.
        • Rilinger N.
        • Sokiranski R.
        • Krämer S.
        • Schütz A.
        • Sunder-Plassmann L.
        • et al.
        Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric artery approach.
        J Endovasc Ther. 2000; 7: 297-301
        • Haq I.U.
        • Kelay A.
        • Davis M.
        • Brookes J.
        • Mastracci T.M.
        • Constantinou J.
        Ten-year single-centre experience with type II endoleaks: intervention versus observation.
        Vasc Med. 2017; (1358863X17704315)
        • Haulon S.
        • Tyazi A.
        • Willoteaux S.
        • Koussa M.
        • Lions C.
        • Beregi J.P.
        Embolization of type II endoleaks after aortic stent-graft implantation: technique and immediate results.
        J Vasc Surg. 2001; 34: 600-605
        • Higashiura W.
        • Greenberg R.K.
        • Katz E.
        • Geiger L.
        • Bathurst S.
        Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms.
        J Vasc Intervent Radiol. 2007; 18: 975-981
        • Hongo N.
        • Kiyosue H.
        • Shuto R.
        • Kamei N.
        • Miyamoto S.
        • Tanoue S.
        • et al.
        Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair.
        J Vasc Intervent Radiol. 2014; 25: 709-716
        • Ishibashi H.
        • Ishiguchi T.
        • Ohta T.
        • Sugimoto I.
        • Iwata H.
        • Yamada T.
        • et al.
        Late events and mid-term results after endovascular aneurysm repair.
        Surg Today. 2014; 44: 50-54
        • Kasirajan K.
        • Matteson B.
        • Marek J.M.
        • Langsfeld M.
        Technique and results of transfemoral superselective coil embolization of type II lumbar endoleak.
        J Vasc Surg. 2003; 38: 61-66
        • Kim M.H.
        • Park H.S.
        • Ahn S.
        • Min S.I.
        • Min S.K.
        • Ha J.
        • et al.
        Chronological change of the sac after endovascular aneurysm repair.
        Vasc Specialist Int. 2016; 32: 150-159