Diagnosis and management of type 2 endoleaks after endovascular aneurysm repair

Endovascular repair is a major treatment advance in patients with large infrarenal abdominal aortic aneurysms. Since the FDA approved two commercial devices 2.5 years ago, over 40,000 patients have undergone this procedure in the United States. Although we have learned a great deal, more than a few mysteries relating to the long-term performance of these devices remain. This results in never-ending surveillance protocols searching for graft failure and aneurysm expansion. One of the especially contentious issues is the management of type 2 endoleaks. Unlike other endoleaks that are related to problems with the graft and/or fixation, this type of leak occurs in patients with properly functioning devices. This is why so much controversy exists about whether or not these patients must be treated. Some advocate "watchful-waiting" intervention only when there is aneurysm expansion. Others routinely treat patients with type 2 endoleaks in an attempt to prevent expansion. As with most controversial topics, if you look carefully, there is more agreement than disagreement between the two groups. In this review, we will first describe the methods used for endoleak diagnosis and treatment. We will then review our current endoleak treatment algorithm and explain its rationale for use.