Comparing Sac Embolization and Inferior Mesenteric Artery Embolization in Preventing Type II Endoleaks Post-EVAR

Abstract

Objective:

To compare the efficacy of sac embolization (SACE) versus inferior mesenteric artery embolization (IMAE) in preventing persistent Type II endoleaks (pT2EL) and promoting aneurysmal sac shrinkage following endovascular aneurysm repair (EVAR) in high-risk patients.

Methods:

From January 2018 to December 2022, 273 EVAR patients were screened, and 75 with patent IMA and high T2EL risk were included. Patients were divided into 2 groups: EVAR with IMAE (33 cases) and EVAR with SACE (42 cases). The primary endpoint was the incidence of pT2EL. Secondary endpoints included sac enlargement, shrinkage, and T2EL-related reintervention. Kaplan-Meier analysis and multivariate regression were used for comparisons.

Results:

SACE was associated with a significantly lower incidence of pT2EL than IMAE (2.4% vs 21.2%, p=0.007; HR: 0.140, 95% CI: 0.034–0.578) and a higher rate of sac shrinkage (>5 mm reduction) (83.3% vs 57.6%, p=0.005; HR: 2.272, 95% CI: 1.286–4.014). Sac enlargement (>5 mm) occurred only in the IMAE group (6.1%, p=0.097). SACE required less contrast use (113.7 ± 24.5 vs 140.5 ± 29.6 mL, P < 0.001) and exhibited a trend toward fewer reinterventions. No ruptures or AAA-related deaths occurred in either group.

Conclusion:

SACE is more effective than IMAE in preventing pT2EL and promoting sac shrinkage in high-risk EVAR patients. These results support SACE as the preferred adjunctive strategy, warranting further multicenter studies with longer follow-up to confirm its benefits and optimize techniques.

Clinical Impact

This study provides comparative evidence on two adjunctive techniques used during EVAR for high-risk patients. Sac embolization (SACE) demonstrated a lower incidence of persistent type II endoleaks and a higher rate of aneurysm sac shrinkage compared with inferior mesenteric artery embolization (IMAE), with reduced contrast use and comparable safety. These findings suggest that SACE may offer a more effective and practical approach for type II endoleak prevention and sac regression, potentially improving long-term outcomes and procedural efficiency in EVAR practice.

Keywords

aneurysm sac shrinkage endovascular aneurysm repair inferior mesenteric artery embolization sac embolization secondary interventions type II endoleak prevention

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References

Paravastu

Jayarajasingam

Cottam

, et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev. 2014;2014(1). https://pubmed.ncbi.nlm.nih.gov/24453068/. Accessed November 4, 2024.

HYH

Lindström

Wanhainen

, et al. An updated systematic review and meta-analysis of pre-emptive aortic side branch embolization to prevent type II endoleaks after endovascular aneurysm repair. J Vasc Surg. 2023;77(6):1815–1821.

Otsu

Ishizaka

Watanabe

, et al. Analysis of anatomical risk factors for persistent type II endoleaks following endovascular abdominal aortic aneurysm repair using CT angiography. Surg Today. 2016;46(1):48–55.

Niklas

Malec

Gutowski

, et al. Effectiveness of inferior mesenteric artery embolization on type II endoleak-related complications after endovascular aortic repair (EVAR): systematic review and meta-analysis. J Clin Med. 2022;11(18):5491.

Takeuchi

Morikage

Samura

, et al. Five-year follow-up of randomized clinical trial for pre-emptive inferior mesenteric artery embolization during endovascular aneurysm repair. J Vasc Surg. 2024;80(3):693–701.e3.

Mascoli

Faggioli

Gallitto

, et al. Tailored sac embolization during EVAR for preventing persistent type II endoleak. Ann Vasc Surg. 2021;76:293–301.

Miura

Kurimoto

Maruyama

, et al. Injection of n-butyl-2-cyanoacrylate into the abdominal aortic aneurysm sac during endovascular aortic repair to prevent type II endoleaks caused by lumbar arteries. J Vasc Interv Radiol. 2024;35(5):676–686.

Mathlouthi

Yei

Guajardo

, et al. Prophylactic perigraft arterial sac embolization during EVAR: minimizing type II endoleaks and improving sac regression. Ann Vasc Surg. 2023;93:103–108.

Piazza

Squizzato

Zavatta

, et al. Outcomes of endovascular aneurysm repair with contemporary volume-dependent sac embolization in patients at risk for type II endoleak. J Vasc Surg. 2016;63(1):32–38.

10.

Samura

Morikage

Mizoguchi

, et al. Identification of anatomical risk factors for type II endoleak to guide selective inferior mesenteric artery embolization. Ann Vasc Surg. 2018;48:166–173.

11.

Piazza

Frigatti

Scrivere

, et al. Role of aneurysm sac embolization during endovascular aneurysm repair in the prevention of type II endoleak-related complications. J Vasc Surg. 2013;57(4):934–941.

12.

Seike

Matsuda

Shimizu

, et al. Nationwide analysis of persistent type II endoleak and late outcomes of endovascular abdominal aortic aneurysm repair in Japan: a propensity-matched analysis. Circulation. 2022;145(14):1056–1066.

13.

Fabre

Mougin

Mitilian

, et al. Prospective, randomised two centre trial of endovascular repair of abdominal aortic aneurysm with or without sac embolisation. Eur J Vasc Endovasc Surg. 2021;61(2):201–209.

14.

Gentsu

Yamaguchi

Sasaki

, et al. Side branch embolization before endovascular abdominal aortic aneurysm repair to prevent type II endoleak: a prospective multicenter study. Diagn Interv Imaging. 2024;105(9):326–335.

15.

Perini

Gargiulo

Silingardi

, et al. Multicenter comparison between open conversions and semi-conversions for late endoleaks after endovascular aneurysm repair. J Vasc Surg. 2022;76(1):104–112.

16.

DeMartino

Breite

Neal

, et al. Incidence, reintervention, and survival associated with type II endoleak at hospital discharge after elective endovascular aneurysm repair in the Vascular Quality Initiative. J Vasc Surg. 2023;78(3):679–686.e1.

17.

Mascoli

Freyrie

Gargiulo

, et al. Selective intra-procedural AAA sac embolization during EVAR reduces the rate of type II endoleak. Eur J Vasc Endovasc Surg. 2016;51(5):632–639.

18.

Midy

Bastrot

Belhomme

, et al. Five year results of the French EPI-ANA-01 registry of AnacondaTM endografts in the treatment of infrarenal abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2020;60(1):16–25.

19.

Bianchini Massoni

Ucci

Perini

, et al. Prevalence, risk factors and clinical impact of intraprosthetic thrombus deposits after EVAR. J Cardiovasc Surg (Torino). 2020;61(6):729–737.

20.

Sasaki

Yamaguchi

Gentsu

, et al. Pre-emptive aortic side branch embolization during endovascular aneurysm repair using the excluder stent-graft system: a prospective multicenter study. J Vasc Interv Radiol. 2024;35(6):874–882.