Type II endoleaks after fenestrated/branched endografting for juxtarenal and pararenal aortic aneurysms

Aim: Persistent type 2 endoleaks (EL2p) are not uncommon after endovascular aneurysm repair and their impact on long-term outcomes is well documented. However, their occurrence and natural history after fenestrated/branched endografting (F/B-EVAR) for juxta/para-renal aneurysms (J/P-AAAs) have been scarcely investigated. Aim of this study was to report incidence, risk-factors and natural history of EL2p after F/B-EVAR in J/P-AAAs. Methods: Between 2016 and 2022, all J/P-AAAs undergoing F/B-EVAR were prospectively collected and retrospectively analyzed. EL2 were assessed at the completion angiography, at 30-day and after 6 months as primary outcomes. Preoperative risk-factors for EL2p, follow-up survival, freedom from reinterventions (FFR) and aneurysm shrinkage (>5mm) were considered as secondar outcomes. Results: Out of 132 patients, there were 88(67%) JAAAs and 44(33%) PAAAs. Seventeen (13%) EL2 were detected at the completion angiography and 36(27%) at 30-day computed tomography angiography. The mean follow-up was 28+23 months. Eleven (31%) EL2 sealed spontaneously within six months and 3 new cases were detected, for an overall of 28 EL2p / 107(26%) patients with available radiological follow-up > 6months. Preoperative antiplatelet therapy (OR:4.7;95%CI:1-22.1;P:0.05), aneurysm thrombus volume <40% and >6 patent aneurysm afferent vessels (OR:7.2;95%CI:1.8-29.1;P:.005) were independent risk-factor for EL2p. Estimated 3-year survival was 80%, with no difference between cases with and without EL2p (78% vs 85%; P:.08). Estimated 3-year FFR was 86%, with no difference between cases with and without EL2p (81% vs 87%; P:.41). Four (3%) cases of EL2-related reinterventions were performed. In 65(49%) cases aneurysm shrinkage was detected. EL2p was an independent risk-factor for absence of aneurysm shrinkage during follow-up (HR: 3.2; 95% CI: 1.2-8.3; P:.014). Patients without shrinkage had lower follow-up survival (64% vs 86% at 3-year; P:.009) and FFR (74% vs 90% at 3-year; P:.014) than patients with shrinkage. Conclusion: EL2p is not infrequent (26%) after F/B-EVAR for J/P-AAAs and is correlated with preoperative antiplatelet therapy, aneurysm thrombus volume < 40% and > 6 patent sac afferent vessels. Patients with EL2p have a diminished aneurysm shrinkage, which is correlated with lower follow-up survival and FFR compared with patients with aneurysm shrinkage.