Rupture prevention after endovascular aneurysm repair focused on sealing zone integrity

The optimal criteria for reintervention after endovascular aneurysm repair (EVAR) remain controversial, particularly for type II endoleak (T2EL)-associated sac enlargement. This study evaluated a post-EVAR rupture prevention strategy prioritizing sealing zone integrity rather than diameter-based thresholds.

This multicenter, retrospective cohort study included 658 patients who underwent EVAR for abdominal aortic aneurysm. Reintervention was not routinely performed for isolated T2EL; instead, decisions were based on compromised sealing zone (CSZ), defined as deterioration of proximal or distal sealing integrity. The primary end point was aneurysm rupture. Secondary outcomes included reintervention and aneurysm-related death.

During a median follow-up of 4.1 years, overall survival was 83.3% at 3 years and 68.5% at 5 years. A total of 83 reinterventions were performed, of which 60 were for sealing-related complications, with a median time to reintervention of 3.9 years (interquartile range, 2.1-6.4). No reintervention was performed for isolated T2EL. Freedom from reintervention was 92.9% at 3 years and 86.7% at 5 years. Twelve ruptures occurred; most were associated with type I endoleaks, whereas no rupture was attributed to isolated T2EL. Among rupture cases, CSZ was identified before rupture in seven patients, with a median interval of 3.1 months from detection to rupture. Three ruptures occurred in patients who were lost to follow-up. Aneurysm-related death occurred in nine patients.

A follow-up strategy prioritizing sealing zone integrity was associated with low rupture rates and limited reintervention. Rupture after EVAR appeared to be more closely associated with sealing failure than with isolated T2EL, supporting surveillance focused on early detection of CSZs while recognizing sac enlargement as an important warning sign rather than a sole trigger for reintervention.