Surgical treatment of persistent type II endoleak, with increase of the aneurysm sac: indications and technical notes

Objective. Unsolved type 2 endoleaks and aneurysmal sac increasing after endovascular aneurysm repair (EVAR) can be fixed with surgical sacotomy, ligation of the patent backbleeding vessels and preservation of the endograft. The aim of the paper is to highlight the technique as a feasible procedure in alternative to the removal of the graft. Materials and methods. Four male patients whose aneurysm sac maximum transverse diameter had increased by 5 mm or more, without evidence of endoleak, migration or structural alteration of the endografts. The surgical access was by medial laparotomy in one case, flank incision in two cases and mini-laparotomy with laparoscopic assistance in the fourth case. Patients were followed with spiral CT and duplex ultrasound at discharge and at 6–12 months. Results. All procedures were carried out, without complication. Two patients required intensive care unit (ICU) admission and the average post-operative hospital stay was 10 days (range 6–13). All patients are currently alive with a functioning endograft, at an average follow-up of 14.7 months. Conclusions. Sacotomy, leaving the endograft in place, appears to be a feasible therapeutic option, less invasive than conversion to open repair. This technique merits further study.