1. 59 y.o. man: acute back pain Leaking AAA s/p EVAR
EVAR Endoleaks – RAML
59 y.o. man: acute back pain
11/7/15 CTA: AAA 6cm, with leak and retroperitoneal hematoma
11/9/15 CTA: 2D s/p Endologix stent-graft repair: short bifurcated body, two proximal sleeves
Leaking AAA
s/p EVAR

2. Surveillance missed. 13 mos. later: acute back pain
EVAR Endoleaks – RAML
Surveillance missed. 13 mos. later: acute back pain
12/8/16 CTA: Type 3 endoleak and acute sac rupture
main body angulated in relation to and separated from proximal components
proximal components slipped distally into sac

3. EVAR Endoleaks EVAR stent-grafts
EVAR Endoleaks – RAML
EVAR Endoleaks
EVAR stent-grafts
purpose: exclude pressure from aneurysm sac, maintain distal flow.
design: self-expanding stents outwardly press microporous fabric against atherosclerotic aortic and iliac walls, and sac thrombus.
materials: push limits of stent and fabric thickness/strength vs. delivery size.
procedure: unlike open graft, no opportunity to ligate or reimplant side branches (lumbar arteries, IMA).
after aneurysm exclusion: sac thrombus matures, reconfigures, hemolyzes.
these principles provide the opportunities for failure (endoleaks) and the requirement for lifelong imaging surveillance.
Endoleaks: classify them with imaging to understand their mechanism, and thus, the urgency and type of repair.

4. Endoleak Classification
EVAR Endoleaks – RAML
Endoleak Classification
Type 1: proximal or distal seals fail: high-pressure leak: URGENT REPAIR
1-month post-op: limb attachment leak: Rx covered stent

5. Endoleak Classification
EVAR Endoleaks – RAML
Endoleak Classification
Type 2: aortic side branches reconstitute flow in sac: lumbars, IMA
low-pressure leak: FOLLOW SAC SIZE
embolize electively if leak persistent AND sac enlarging

6. Endoleak Classification
EVAR Endoleaks – RAML
Endoleak Classification
Type 3: graft disruption: fabric tear, component separation
high-pressure leak: URGENT REPAIR

7. Endoleak Classification
EVAR Endoleaks – RAML
Endoleak Classification
Type 4: porous fabric: usually seen while still anticoagulated postop.
low-pressure leak: await reversal of anticoagulation.
Type 5: “endotension”: sac growth in the absence of a visible leak.
low-pressure leak: re-line stent-graft electively if sac enlarging

8. EVAR Endoleaks – RAML
Summary
Endoleaks: classify them with imaging to understand their mechanism, and thus, the urgency and type of repair.
High-pressure leaks: URGENT repair with covered stents
Type 1: proximal or distal seals fail
Type 3: graft disruption: fabric tear, component separation
Low-pressure leaks: treat electively if sac enlarging
Type 2: aortic side branches reconstitute flow in sac: lumbars, IMA
Type 4: porous fabric: usually seen while still anticoagulated postop
Type 5: “endotension”: sac growth in the absence of a visible leak
Radiology 2007;243: AJR 2009:192:W178-W186)