Management of type II endoleaks: preoperative versus postoperative versus expectant management

Type II endoleak is a common phenomenon after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Most type II endoleaks are innocuous and transient and therefore do not require intervention. However, particularly persistent endoleaks could lead to aneurysm enlargement and delayed aortic rupture. Decreasing the occurrence rates of type II endoleaks can be attempted with prophylactic occlusion of the inferior mesenteric, hypogastric, and lumbar arteries. Although the efficacy and clinical benefit of prophylactic occlusion of aortic branches prior to EVAR or during the endovascular repair remain controversial, we anticipate an increased use of intraoperative embolization techniques. A reasonable treatment strategy in patients with type II endoleak may be to intervene in cases of increasing aneurysm size or if the endoleak does not resolve spontaneously within 6 months. Translumbar embolization has been shown to be more effective than transarterial embolization. An alternative embolization technique is transcaval embolization, which has shown success rates comparable to translumbar embolization. Type II endoleaks can also be treated during laparoscopy or laparotomy, but these techniques are more invasive and should be used only after failure of embolization techniques.