Endovascular aneurysm repair for abdominal aortic aneurysm: progress and reflection in diagnosis and management of type <b>Ⅱ</b> endoleak_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

CAO Leihan ^1,2,3 , GE Jinting ¹ , WENG Chengxin ¹ , WANG Tiehao ¹ ,  YUAN Ding ¹

1. Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. West China School of Medicine, Sichuan University, Chengdu 610041, P. R. China;
3. Department of General Surgery, The Fourth People’s Hospital of Sichuan Province, Chengdu 610016, P. R. China;

Corresponding?author：

YUAN Ding, Email: yuanding@wchscu.cn

Keywords：

type Ⅱ endoleak; pathophysiological mechanism; diagnosis; treatment

DOI：

10.7507/1007-9424.202512116

Video：

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Objective To comprehensively summarize the latest research advances in the epidemiology, pathophysiological mechanisms, imaging diagnostic techniques, and clinical intervention strategies of type Ⅱ endoleak after endovascular abdominal aortic aneurysm repair, so as to provide references for clinical diagnosis and treatment. Methods Relevant foreign literatures published in recent years were systematically retrieved, and the research on pathophysiological mechanisms, diagnostic methods and treatment strategies of type Ⅱ endoleak was summarized, analyzed and reviewed. Results The core value of matrix metalloproteinases and tissue inhibitors of metalloproteinases in type Ⅱ endoleak lies in diagnosis prediction and disease monitoring. These molecules may be involved in the pathological process of type Ⅱ endoleak, yet their specific mechanisms of action require further investigation. Computed tomography angiography remains the “gold standard” for the diagnosis of type Ⅱ endoleak, while contrast-enhanced ultrasound and magnetic resonance imaging/magnetic resonance angiography can serve as effective supplements. Prophylactic embolization of collateral arteries plays a certain role in delaying the occurrence of type Ⅱ endoleak. Clinical interventions include conservative observation with regular follow-up, endovascular embolization and open surgery, yet a consensus on the optimal regimen has not been reached. Conclusions Clinical diagnosis and treatment of type Ⅱ endoleak still face numerous challenges. In the future, large-sample and multicenter clinical trials should be conducted to clarify the characteristics of its natural course, optimize follow-up and intervention protocols, and further explore its pathophysiological mechanisms, so as to provide new theoretical basis and technical support for the precise diagnosis and treatment of type Ⅱ endoleak.

Citation： CAO Leihan, GE Jinting, WENG Chengxin, WANG Tiehao, YUAN Ding. Endovascular aneurysm repair for abdominal aortic aneurysm: progress and reflection in diagnosis and management of type Ⅱ endoleak. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2026, 33(3): 389-397. doi: 10.7507/1007-9424.202512116 Copy

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2. Bown MJ, Sutton AJ, Bell PR, et al. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg, 2002, 89(6): 714-730.
3. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg, 1991, 13(3): 452-458.
4. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet, 2015, 385(9963): 117-171.
5. Mureebe L, Egorova N, Giacovelli JK, et al. National trends in the repair of ruptured abdominal aortic aneurysms. J Vasc Surg, 2008, 48(5): 1101-1107.
6. Sampson UK, Norman PE, Fowkes FG, et al. Global and regional burden of aortic dissection and aneurysms: mortality trends in 21 world regions, 1990 to 2010. Glob Heart, 2014, 9(1): 171-180.
7. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg, 1991, 5(6): 491-499.
8. Lederle FA, Freischlag JA, Kyriakides TC, et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med, 2012, 367(21): 1988-1997.
9. Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA, 2009, 302(14): 1535-1542.
10. EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet, 2005, 365(9478): 2179-2186.
11. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med, 2004, 351(16): 1607-1618.
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13. Dueppers P, D’Oria M, Lepidi S, et al. An expert-based review on the relevance and management of type 2 endoleaks following endovascular repair of ruptured abdominal aortic aneurysms. J Clin Med, 2024, 13(15): 4300. doi: 10.3390/jcm13154300.
14. Niklas N, Malec M, Gutowski P, 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. doi: 10.3390/jcm11185491.
15. Avgerinos ED, Chaer RA, Makaroun MS. Type Ⅱ endoleaks. J Vasc Surg, 2014, 60(5): 1386-1391.
16. Seike Y, Matsuda H, Shimizu H, 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.
17. El Batti S, Cochennec F, Roudot-Thoraval F, et al. Type Ⅱ endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition. J Vasc Surg, 2013, 57(5): 1291-1297.
18. Chun JY, de Haan M, Maleux G, et al. CIRSE standards of practice on management of endoleaks following endovascular aneurysm repair. Cardiovasc Intervent Radiol, 2024, 47(2): 161-176.
19. Partovi S, Trischman T, Rafailidis V, et al. Multimodality imaging assessment of endoleaks post-endovascular aortic repair. Br J Radiol, 2018, 91(1087): 20180013. doi: 10.1259/bjr.20180013.
20. D’Oria M, Mastrorilli D, Ziani B. Natural history, diagnosis, and management of type Ⅱ Endoleaks after endovascular aortic repair: review and update. Ann Vasc Surg, 2020, 62: 420-431.
21. Rokosh RS, Wu WW, Dalman RL, et al. Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: endoleak management. J Vasc Surg, 2021, 74(6): 1792-1794.
22. Dijkstra ML, Zeebregts CJ, Verhagen HJM, et al. Incidence, natural course, and outcome of type Ⅱ endoleaks in infrarenal endovascular aneurysm repair based on the ENGAGE registry data. J Vasc Surg, 2020, 71(3): 780-789.
23. Koudounas G, Giannopoulos S, Charisis N, et al. Understanding type Ⅱ endoleak: a harmless imaging finding or a silent threat? J Clin Med, 2024, 13(14): 4250. doi: 10.3390/jcm13144250.
24. Takagi H, Manabe H, Kawai N, et al. Circulating matrix metalloproteinase-9 concentrations and abdominal aortic aneurysm presence: a meta-analysis. Interact Cardiovasc Thorac Surg, 2009, 9(3): 437-440.
25. Fiotti N, Calvagna C, Sgorlon G, et al. Multiple sites of vascular dilation or aneurysmal disease and matrix metalloproteinase genetic variants in patients with abdominal aortic aneurysm. J Vasc Surg, 2018, 67(6): 1727-1735.
26. D’Oria M, Di Girolamo FG, Calvagna C, et al. Remodeling of abdominal aortic aneurysm sac following endovascular aortic repair: association with clinical, surgical, and genetic factors. Cardiovasc Pathol, 2022, 58: 107405. doi: 10.1016/j.carpath.2021.107405.
27. Adovasio R, Calvagna C, Sgorlon G, et al. Growth rate of small abdominal aortic aneurysms and genetic polymorphisms of matrix metalloproteases-1, -3, and -9. Int J Angiol, 2016, 25(2): 93-98.
28. Hellenthal FA, Ten Bosch JA, Pulinx B, et al. Plasma levels of matrix metalloproteinase-9: a possible diagnostic marker of successful endovascular aneurysm repair. Eur J Vasc Endovasc Surg, 2012, 43(2): 171-172.
29. Sangiorgi G, D’Averio R, Mauriello A, et al. Plasma levels of metalloproteinases-3 and -9 as markers of successful abdominal aortic aneurysm exclusion after endovascular graft treatment. Circulation, 2001, 104(12 Suppl 1): I288-I295.
30. Georgiadis GS, Antoniou GA, Argyriou C, et al. Correlation of baseline plasma and inguinal connective tissue metalloproteinases and their inhibitors with late high-pressure endoleak after endovascular aneurysm repair: long-term results. J Endovasc Ther, 2019, 26(6): 826-835.
31. Wilson WR, Anderton M, Choke EC, et al. Elevated plasma MMP1 and MMP9 are associated with abdominal aortic aneurysm rupture. Eur J Vasc Endovasc Surg, 2008, 35(5): 580-584.
32. Moxon JV, Ng E, Lazzaroni SM, et al. Circulating biomarkers are not associated with endoleaks after endovascular repair of abdominal aortic aneurysms. J Vasc Surg, 2018, 67(3): 770-777.
33. Nakamura E, Akashi H, Hiromatsu S, et al. Azelnidipine decreases plasma matrix metalloproteinase-9 levels after endovascular abdominal aortic aneurysm repair. Kurume Med J, 2009, 56(1-2): 25-32.
34. Secchi F, Capra D, Monti CB, et al. Safe follow-up after endovascular aortic repair with unenhanced MRI: the SAFEVAR study. Diagnostics (Basel), 2022, 13(1): 20. doi: 10.3390/ diagnostics13010020.
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CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Endovascular aneurysm repair for abdominal aortic aneurysm: progress and reflection in diagnosis and management of type Ⅱ endoleak

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