Exploring Type IIIb Endoleaks: A Literature Review to Identify Possible Physical Mechanisms and Implications

Endoleaks are common complications following endovascular aneurysm repair (EVAR). They can be classified into low-pressure and high-pressure endoleaks. High-pressure endoleaks, which include Type I and Type III endoleaks, pose a significant risk of rupture and require urgent treatment. The aim of our study is to review published case reports and case series to assess the impact of Type IIIb endoleaks in EVAR and to identify possible mechanisms contributing to these endoleaks. This review targeted case reports and case series published between January 1998 and December 2022. A total of 62 case reports and case series were identified, encompassing 156 patients with Type IIIb endoleaks. Data collection was performed by three consultants who thoroughly discussed each report before registering it into an analyzable data set. Our analysis revealed that, beyond material imperfections, certain endograft configurations or conformations, endograft redundancy, and the physical forces acting on the grafts may lead to increased stress on specific parts of the endografts, potentially exceeding their design limits. Factors contributing to redundancy and unfavorable conformation of the endograft include secondary interventions for any cause (such as other types of endoleaks), EVAR performed outside the instructions for use (IFUs), endograft migrations, or larger initial aneurysm diameter.