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The relevance of late endoleaks following EVAR:implications for follow-up imaging protocols

Caron B. Rockman, MD, Thomas S. Maldonado, MD, Neal S. Cayne, MD, Glenn R. Jacobowitz, MD, Mark A. Adelman, MD, Paul J. Gagne, MD, Matthew M. Nalbandian, MD, Patrick J. Lamparello, MD and Thomas S. Riles, MD
New York University Medical Center, New York, NY

Introduction:
Lifelong follow-up is felt to be mandatory following EVAR. This has generally consisted of CT scans with IV contrast. The cumulative effect of repeated IV contrast, as well as radiation exposure, is unknown. The objective of this study was to analyze our EVAR experience, with specific attention to the incidence of late endoleaks, and to determine the possible implications for the necessity of yearly long-term follow-up.
Methods: A review was conducted of a prospectively maintained database of 327 EVAR’s performed at our institution. An endoleak was classified as “early” if it was first diagnosed within 24 months of EVAR, and “late” if it was first diagnosed thereafter.
Results: A total of 98 patients had an endoleak diagnosed at some time during their follow-up (29.9%). Of these, 82 (81.6%) were diagnosed within the 1st year following EVAR, 6 (6.1%) were diagnosed from the 1st to 2nd postoperative year, and 8 (8.2%) were diagnosed after two years. Of the 327 patients, 237 (72.5%) had at least one year of follow-up with a minimum of two postoperative CT scans, and form the denominator for the remainder of the analysis. The mean follow-up time of these 237 patients was 33 months (12-126 months). Of these 237, 83 (35%) had an endoleak diagnosed at some time during their follow-up. Only 8 of these endoleaks were diagnosed after 2 years (3.4%). Six of these eight late endoleaks were type II leaks, and two were type I leaks. Four of these late endoleaks (including the two type I leaks) were treated successfully endovascularly, three sealed spontaneously, and one remains open with a stable AAA size. Therefore, of 237 patients with at least 1 year of follow-up following EVAR, only 4 patients (1.7%) had endoleaks requiring treatment which were first diagnosed after 24 months of follow-up. There was no significant difference between early and late endoleaks with regard to the percentage that sealed spontaneously (30.3% vs. 37.5%, p=NS), or the percentage which required treatment (34.2% vs. 50%, p=NS). There was no significant difference in the mean change in aneurysm diameter between patients with late leaks and patients with early leaks (mean -1.3 mm vs. -5.7 mm, p=NS).
Conclusions: In patients with at least one year of follow-up following EVAR, the incidence of late endoleaks diagnosed after 24 months is low (3.4%), and of those requiring treatment is even lower (1.7%). Clinically, late endoleaks do not appear to behave differently from early endoleaks. Therefore, the necessity of performing CT scans with IV contrast on a yearly basis in patients with two years of negative follow-up following EVAR is questionable. Considering the potential risks of cumulative contrast and radiation exposure, protocols involving biannual follow-up, perhaps with MRA, US, or CT scans without IV contrast should be aggressively investigated.