What is the management approach for a patient with a history of abdominal aortic aneurysm (AAA) repair presenting with concerns of endoleak?

From the Guidelines

Patients with a history of abdominal aortic aneurysm (AAA) repair presenting with concerns of endoleak should undergo baseline surveillance imaging with CT, and if no evidence of endoleak or sac enlargement is found, continued surveillance with duplex ultrasound at 12 months and then annually thereafter is recommended. The management approach for such patients is guided by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.

Key Considerations

• The role of routine surveillance after EVAR is to identify endoleak, sac growth, endograft migration, or endograft failure 1.
• CT is the gold standard for follow-up imaging after EVAR, but duplex ultrasound can be used for surveillance if no concerning findings are observed on initial CT imaging 1.
• In patients with AAA treated with EVAR who are undergoing annual surveillance imaging with duplex ultrasound, additional cross-sectional imaging with CT or MRI of the abdomen and pelvis every 5 years postoperatively is reasonable 1.

Surveillance and Follow-up

• Patients with AAA treated with EVAR should have baseline surveillance imaging with CT, and if there is no evidence of endoleak or sac enlargement, continued surveillance with duplex ultrasound at 12 months and then annually thereafter is recommended 1.
• In patients with abnormal findings on surveillance duplex ultrasound, additional cross-sectional imaging with CT or MRI is reasonable 1.
• For patients with AAA who have undergone open repair, surveillance imaging with CT or MRI of the abdominopelvic aorta within 1 year postoperatively and then every 5 years thereafter is reasonable 1.

Additional Recommendations

• Blood pressure control and statin therapy are essential to reduce stress on the repair and stabilize the vascular disease process, although specific details on these aspects are not provided in the referenced guideline 1.
• The approach to managing endoleaks depends on their classification, with Type I and Type III endoleaks typically requiring immediate intervention, while Type II endoleaks may be observed if the aneurysm sac is stable 1.

From the Research

Management Approach for Endoleak after AAA Repair

The management approach for a patient with a history of abdominal aortic aneurysm (AAA) repair presenting with concerns of endoleak involves several key considerations:

• Type of Endoleak: The type of endoleak (Type I, II, III, or IV) plays a crucial role in determining the management approach 2.
• Imaging Surveillance: Lifelong imaging surveillance is recommended to detect endoleaks, with dual-energy computed tomography (DECT) being a viable option due to its similar diagnostic accuracy to triphasic single energy computed tomography (SECT) and lower radiation dose 3.
• Treatment Options: Type I endoleaks represent a persistent risk of aneurysm rupture and should be treated promptly by endovascular means, while Type II leaks are less dangerous and more difficult to treat, but coil embolization of feeding arteries may be warranted when leakage is associated with aneurysm enlargement 2.
• Incidence and Fate of Endoleaks: The incidence and fate of endoleaks vary between ruptured and elective endovascular abdominal aortic aneurysm repair, with patients undergoing ruptured EVAR experiencing a similar incidence of type I endoleaks and a significantly lower incidence of type II endoleaks 4.

Diagnostic Accuracy of DECT

The diagnostic accuracy of DECT for detecting endoleaks has been evaluated in several studies, with a meta-analysis suggesting that DECT has similar diagnostic accuracy to triphasic SECT for diagnosing endoleak after endovascular aneurysm repair, with a pooled sensitivity of 94.0% and specificity of 98.9% 3.

Clinical Relevance

The management of endoleaks after AAA repair is crucial to prevent aneurysm rupture and ensure patient safety. The use of DECT for imaging surveillance and the prompt treatment of Type I endoleaks can help reduce the risk of aneurysm rupture and improve patient outcomes 2, 4, 3. Additionally, abdominal ultrasonography is the preferred modality to screen for abdominal aortic aneurysm due to its cost-effectiveness and lack of exposure to ionizing radiation 5.