Journal of vascular surgery · 2026
Early and follow-up results of reinterventions for type 2 endoleak following endovascular repair of abdominal aortic aneurysm (EVAR): the multicenter REinterventions for Type 2 Endoleak (RETE) study.
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Falso Roberto, Speziali Sara, Perini Paolo, Leone Nicola, Esposito Davide, Campolmi Marco, Kahlberg Andrea L, Troisi Nicola, Dorigo Walter, Pulli Raffaele, RETE study collaborators
Аннотация
BACKGROUND: Type II endoleak (T2EL) is frequent after endovascular abdominal aortic aneurysm repair (EVAR) and may require reintervention in selected patients. However, the optimal treatment strategy for durable resolution remains uncertain. The aim of this study is to retrospectively analyze perioperative and long-term results of T2Els' reinterventions, both endovascular and open surgical, in a large patient cohort from twenty high-volume academic centers.
METHODS: A retrospective analysis of consecutive patients undergoing first reintervention for T2ELs was conducted across 20 centers over a 10-year period. Patients requiring concomitant treatment for other endoleak types were excluded. A total of 403 patients were included. Primary outcomes included technical success, 30-day AAA-related mortality and reintervention-free survival during follow-up. Secondary outcomes were perioperative complications, early reintervention, overall survival, freedom from aneurysm-related death and rupture, freedom from recurrent endoleaks, freedom from open conversion or semi-conversion in patients previously treated endovascularly and sac behavior during follow-up. Kaplan-Meier curves and Cox regression analyses were performed to analyze follow-up results.
RESULTS: Patients were predominantly male (90%) with a mean age of 77 years. Reintervention was indicated for sac enlargement in 94.5% of cases; 4% presented with rupture. Median time from EVAR to reintervention was 4.3 years. Lumbar arteries (55%) and the inferior mesenteric artery (35%) were the main sources. Endovascular treatment was performed in 86% and open conversion/semi-conversion in 14%. Technical success was 96%, with 1% mortality and 4% major complications. Overall survival was 80.5% and rupture-free survival 79.2% at 5 years. Recurrent T2EL occurred in 64.2%, and reintervention-free survival was 48.3%. Endovascular group showed significantly lower freedom from reintervention rates when compared to open conversion/semi conversion group (42.4% vs 86.8%, SE 0.04 vs SE 0.05, p<0.001, log-rank 15.9). Conversion/semi-conversion after endovascular treatment occurred in 14%. No differences were recorded comparing different fabric materials of the endograft in terms of freedom for reintervention and freedom from open surgery. A sac diameter ≥7 cm at the time of reintervention predicted further reinterventions, while primary open treatment improved durability.
CONCLUSIONS: Reinterventions for T2ELs are safe, with satisfactory immediate technical success and low perioperative mortality. During follow-up, risks of rupture and AAA-related death remain low. However, the endoleak recurrence rate exceeds 60% at five years, necessitating reintervention in over 40% of patients. Early intervention for patients with a sac diameter approaching 7 cm can be suggested, while a primary open approach may be considered in low-risk patients.
METHODS: A retrospective analysis of consecutive patients undergoing first reintervention for T2ELs was conducted across 20 centers over a 10-year period. Patients requiring concomitant treatment for other endoleak types were excluded. A total of 403 patients were included. Primary outcomes included technical success, 30-day AAA-related mortality and reintervention-free survival during follow-up. Secondary outcomes were perioperative complications, early reintervention, overall survival, freedom from aneurysm-related death and rupture, freedom from recurrent endoleaks, freedom from open conversion or semi-conversion in patients previously treated endovascularly and sac behavior during follow-up. Kaplan-Meier curves and Cox regression analyses were performed to analyze follow-up results.
RESULTS: Patients were predominantly male (90%) with a mean age of 77 years. Reintervention was indicated for sac enlargement in 94.5% of cases; 4% presented with rupture. Median time from EVAR to reintervention was 4.3 years. Lumbar arteries (55%) and the inferior mesenteric artery (35%) were the main sources. Endovascular treatment was performed in 86% and open conversion/semi-conversion in 14%. Technical success was 96%, with 1% mortality and 4% major complications. Overall survival was 80.5% and rupture-free survival 79.2% at 5 years. Recurrent T2EL occurred in 64.2%, and reintervention-free survival was 48.3%. Endovascular group showed significantly lower freedom from reintervention rates when compared to open conversion/semi conversion group (42.4% vs 86.8%, SE 0.04 vs SE 0.05, p<0.001, log-rank 15.9). Conversion/semi-conversion after endovascular treatment occurred in 14%. No differences were recorded comparing different fabric materials of the endograft in terms of freedom for reintervention and freedom from open surgery. A sac diameter ≥7 cm at the time of reintervention predicted further reinterventions, while primary open treatment improved durability.
CONCLUSIONS: Reinterventions for T2ELs are safe, with satisfactory immediate technical success and low perioperative mortality. During follow-up, risks of rupture and AAA-related death remain low. However, the endoleak recurrence rate exceeds 60% at five years, necessitating reintervention in over 40% of patients. Early intervention for patients with a sac diameter approaching 7 cm can be suggested, while a primary open approach may be considered in low-risk patients.