A systematic review of treatment modalities and outcomes of type Ib endoleak after endovascular abdominal aneurysm repair

Abstract

Objectives

To collect specific literature on type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm, reporting data on diagnosis, treatment, and follow-up results.

Methods

Publications about type Ib endoleak after aorto-iliac endografting for abdominal aortic or iliac aneurysm were searched in PubMed, Web of Science, and Scopus. Considered studies were in English and published until 3 November 2016. Research methods and reporting were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were: (1) reporting on abdominal aortic or iliac aneurysm as primary diagnosis; (2) reporting on distal endoleak after aorto-iliac endografting. Patient data, data on endovascular treatment, endoleak, reintervention, and follow-up were collected by two independent authors.

Results

Included studies were 11 (five original articles, six case reports), corresponding to 29 patients and 30 type Ib endoleak. Excluding missing data (2/30, 6.7%), type Ib endoleak was treated intra-operatively, within six months and after six months in six cases (21.4%), eight cases (28.6%), and fourteen cases (50%), respectively. Treatment of type Ib endoleak was endovascular in 27 cases (90%) (7 embolizations + extender cuffs, 10 extender cuffs, 8 embolizations without extender cuff, 1 Palmaz stenting and 1 iliac branched endograft), hybrid in 1 case (3.3%) and surgical in 2 cases (6.6%). Buttock claudication occurred in two cases (6.7%). One-month mortality was 3.4% (2/29) without events due to type Ib endoleak. In 14 cases (46.7%), median follow-up was six months (interquartile range: 2.75–14; range: 0.75–53). Type Ib endoleak persisted or reappeared in three cases (10%), all after endovascular treatment. Two of these (2/3, 66.7%) needed endovascular reintervention. No death during follow-up was reported.

Conclusions

Few specific data are available in literature about type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm. About 50% of type Ib endoleak occurred after six months from the endovascular abdominal aneurysm repair procedure. Treatment is mainly endovascular and distal endograft extension is the main and effective treatment. Buttock claudication is the most frequent complication in case of exclusion of internal iliac artery. Persistent type Ib endoleak is possible, and adjunctive endovascular procedures are necessary.

Keywords

Endoleak aortic aneurysm abdominal endovascular procedures type I endoleak type Ib endoleak endovascular abdominal aneurysm repair

Introduction

Type I endoleak is defined as the persistent perfusion of the aneurysm sac from the proximal (type Ia) or distal (type Ib) edge of the endograft, following endovascular abdominal aneurysm repair (EVAR).¹ According to the guidelines of the Society for Vascular Surgery,² a type I endoleak is “linked to a continued risk of rupture.” In fact, the type I endoleak represents the leading cause of late rupture after EVAR in a recent meta-analysis by Antoniou et al.³

Type Ib endoleak (IbELs) is associated with large common iliac arteries (16–22 mm in diameter)⁴ or tortuous iliac axis.⁵ Literature about IbEL is very scant. To the best of our knowledge, only few dedicated experiences are reported in literature regarding incidence, presentation, and treatment of iliac IbEL, and no studies are available about the difference between type Ia and IbEL in terms of aneurysm rupture risk.

The aim of this systematic review is to collect specific literature on IbEL after aorto-iliac endografting, reporting data on diagnosis, frequency, treatment options, and follow-up results.

Materials and methods

Search strategy

The scientific publications about IbEL after EVAR for abdominal aortic or iliac aneurysm were searched in PubMed, Web of Science and Scopus. Reference lists of articles were also scanned to add suitable studies. Literature in English language published until 3 November 2016 was considered. The research was conducted by two authors (CBM and PP) and, in case of controversies, a consensus was reached. Strings entered in search boxes were: in PubMed “endoleak AND (type I[ti] or type 1[ti] or type Ib[ti] or type 1b[ti]),” in Web of Sciences “TS = endoleak AND (TI = type I OR TI = type 1 OR TI = type Ib OR TI = type 1b)” and in Scopus “endoleak AND TITLE (TYPE I) OR TITLE (TYPE 1) OR TITLE (TYPE Ib) OR TITLE (TYPE 1b).” Research methods and reporting were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.⁶

Study selection

Inclusion criteria were: (1) reporting on abdominal aortic aneurysm (AAA) or iliac aneurysm as primary diagnosis and (2) reporting on distal endoleak after aorto-iliac endografting (distal sealing zone in iliac artery). Case reports were included. Articles dealing with endografting in other arterial segments (e.g. thoracic, popliteal) or in the abdominal aorta without iliac endograft extension were excluded. Additional exclusion criteria were: aortic dissection, type Ia (proximal) EL, not-specified type I endoleak, use of multilayer flow modulator, previous aortic surgery without endografting, commentary, review, experimental or in vitro study, no full text availability. Eligibility of the study was assessed after reading of the full text by CBM and PP and controversies resolution. In case of studies containing duplicate data, only the most recent one was included.

Data extraction

Extracted data were classified in several categories: patient data (number, age, and gender), data on endovascular treatment (indication, endograft configuration and type, and adjunctive procedures), endoleak data (time of diagnosis, localization of the IbEL, associated endoleaks), reintervention data (type, description, complications, mortality), and follow-up data (length, reintervention, mortality).

The type of IbEL repair was classified in endovascular, hybrid, and surgical. All not-deducible data were reported as “not specified.” Data were independently extracted by two vascular surgeons (CMB, PP) and incongruous data were solved together.

Results

Search results

The flowchart for the study selection is shown in Figure 1. Overall, 11 studies were included in the systematic review, corresponding to five original articles and six case reports. No specific original articles on IbEL were found. Specific data on selected studies are reported in Table 1.^7–17

Figure 1.

Flow chart of study selection.

Table 1.

Data on included studies, patient demographics, and indication of treatment.

N	Author(s)	Year of publication	Type	Specific for type Ib EL	Number of patient	Gender	Age (y)	Indication	Maximum diameter (mm)
1	Maldonado et al.⁷	2003	Original article	No	7	ns: 7	ns: 7	AAA	ns
2	Pereira et al.⁸	2005	Case report	Yes	1	Male	73	AAA and bilateral common iliac artery aneurysms	ns
3	Keo et al.⁹	2006	Case report	Yes	1	Male	84	Infrarenal AAA	70
4	Choi et al.¹⁰	2011	Original article	No	2	ns: 2	ns: 2	Infrarenal AAA	58
4	Choi et al.¹⁰	2011	Original article	No	2	ns: 2	ns: 2	Infrarenal AAA	79
5	Henrikson et al.¹¹	2011	Original article	No	1	Male	ns	AAA	ns
6	Naughton et al.¹²	2011	Original article	No	12	Male: 2	77±10	Aorto-iliac aneurysm disease	ns
6	Naughton et al.¹²	2011	Original article	No	12	ns: 10	77±10	Aorto-iliac aneurysm disease	ns
7	Ahn et al.¹³	2012	Case report	Yes	1	Male	86	AAA (66 mm) + right internal iliac artery aneurysm (40 mm)	66 + 40
8	Faccenna et al.¹⁴	2012	Case report	Yes	1	Male	86	AAA	70
9	Chun and Morgan¹⁵	2013	Original article	No	1	Male	68	Thoracoabdominal aortic dissection +infrarenal AAA	ns
10	Kordzadeh et al.¹⁶	2014	Case report	Yes	1	Male	80	Infrarenal AAA	60
11	Vourliotakis et al.¹⁷	2016	Case report	Yes	1	Male	78	AAA+occlusion of left CIA,EIA,IIA	92

AAA: abdominal aortic aneurysm; CIA: common iliac artery; EIA: external iliac artery; EL: endoleak; IIA: internal iliac artery; ns: not specified.

Patients and EVAR procedure

Total number of included patients was 29. Patients’ demographics are summarized in Table 1. Details about configuration, type of deployed endograft, and adjunctive procedures are summarized in Table 2.

Table 2.

Data on endovascular procedure and endoleak.

N	Author(s)	Number of patient	Endovascular procedure	Type of endograft	Diagnosis of Ib EL	Localization of Ib EL	Cause of Ib EL	Associated EL
1	Maldonado et al.⁷	7	Aorto-bi-iliac endograft: 7	Bifurcated EVT/Ancure or AneuRx	Intraoperative: 4Within 1 month: 11–6 months: 1>6 months: 1	ns: 7	ns	ns: 7
2	Pereira et al.⁸	1	Right aorto-uni-iliac stentgraft + contralateral blocking stent in left iliac artery + femoro-femoral crossover bypass	ELLA, (Hradec Kralove, Czech Republic)	At 3 months	From right iliac artery from proximal migration of aorto-uni-iliac endograft into the aorta	Cranial migration	No
3	Keo et al.⁹	1	Aorto-bi-iliac endograft	ns	At 1 monthAt 5 months	Left iliac limbRight iliac limb	ns	No: 2
4	Choi et al.¹⁰	2	Aorto-bi-iliac: 2	ns: 2	ns: 2	Left iliac limbns	Tortuosity of iliac artery: 1 ns: 1	No Ia
5	Henrikson et al.¹¹	1	Standard EVAR	Endurant, Medtronic	Intraoperative	Right common iliac artery	Conical and dilated common iliac artery	No
6	Naughton et al.¹²	12	Standard EVAR: 11Custom-made EVAR: 1	Excluder: 5AneuRx: 4Ancure: 2ns:1	Median: 3.5 years (range: 0.1–11)	ns: 12	ns: 12	Ia + III: 1Ia: 2No: 9
7	Ahn et al.¹³	1	Aorto-bifurcated endograft with embolization of right internal iliac artery (22 mm Amplatzer Vascular Plug) and distal sealing zone in right external iliac artery	Zenith Flex	Intraoperative		Inadequate radial force (scarce oversize)	No
8	Faccenna et al.¹⁴	1	Aorto-bi-iliac endograft	AneuRx	8 years	Right iliac limb	ns	III (disconnection of contralateral iliac limb)
9	Chun and Morgan¹⁵	1	Hybrid aortic repair (3 visceral artery bypass graft from distal right common iliac artery and throracic endografts deployment)	ns	6 years	Right common iliac artery	ns	No
10	Kordzadeh et al.¹⁶	1	Aorto-bi-iliac endograft	Anaconda	4 years	Left common iliac artery	ns	No
11	Vourliotakis et al.¹⁷	1	Right aorto-uni-iliac endograft	ns	2 months	Right common iliac artery (aneurysm 54 mm in diameter)	ns	No

EL: endoleak; ns: not specified.

Ib endoleaks

Total number of IbEL was 30. Specific data on endoleaks are reported in Table 2. Data about the timing of the repair of IbEL were missing in 2/30 cases (6.7%). IbEL were treated intra-operatively, within 6 months and after 6 months in 6 cases (21.4%, 6/28), 8 cases (28.6%, 8/28), and 14 cases (50%, 14/28), respectively. Associated endoleaks were detected in five cases (16.7%): three type Ia, one type III, and one type Ia associated with a type III.

Treatment of IbEL

Specific data about endoleak management are shown in Table 3. Treatment of IbEL was endovascular in 27 cases (90%): 7 embolizations of the internal iliac artery associated with endograft iliac extensions, 10 endograft iliac extensions, 8 embolizations without iliac extensions (four with n-Butyl 2 cyanoacrylate (n-BCA), two with Onyx (ev3 Inc., Irvine, CA), 1 with coils, 1 with n-BCA associated with coils), one Palmaz stent, one iliac branched endograft. A hybrid approach was performed in one case (3.3%, one aorto-uni-iliac endograft with contralateral iliac plug and femoro-femoral sovrapubic bypass grafting). Open surgery was performed in two cases (6.6%, one aorto-bi-iliac bypass graft in emergency setting, one dacron bypass graft between the distal portion of endograft and the external iliac artery with ligation of the right internal iliac artery).

Table 3.

Data on treatment of type Ib endoleak and follow-up.

N	Author(s)	Number of patient	Type of treatment	Description	Note	Follow-up	Complication	Treatment of complication
1	Maldonado et al.⁷	7	Endovascular: 7	n-BCA: 3Extender cuffs or covered Wallgraft: 3Coil embolization: 1		6 months	Contrast medium in iliac aneurysm sac• No: 3• ns: 3	ns: 4No: 3
1	Maldonado et al.⁷	7	Endovascular: 7			ns: 6	Contrast medium in iliac aneurysm sac• No: 3• ns: 3	ns: 4No: 3
2	Pereira et al.⁸	1	Hybrid	Infrarenal aortic endovascular clamping (from right brachial access), dacron bypass graft between distal portion of endograft and external iliac artery with ligation of right internal iliac artery (ectatic) (from retroperitoneal approach)	Failed endovascular attempt for incarceration of uni-iliac endograft into the contralateral iliac aneurysm	4 months	Mild right buttock claudication (subsided after 6 weeks)	No
3	Keo et al.⁹	1	Endovascular	Coil embolization of left internal iliac artery and stentgraft extension		34 months	Left minor buttock claudication	No
3	Keo et al.⁹	1	Endovascular	Endograft extension (Medtronic Talent) in right common iliac artery. Reintervention the same day for dissection of right common iliac artery.	Associated with disseminated intravascular coagulopathy	30 months	No	No
4	Choi et al.¹⁰	2	Endovascular: 2	Transarterial N-butyl cyanoacrylate embolization	Balloon angioplasty had already failed	>53 months	No (8 mm shrinkage)	No
4	Choi et al.¹⁰	2	Endovascular: 2	Transabdominal N-butyl cyanoacrylate embolization and coil embolization of aneurysmal sac and inferior mesenteric artery	Aortic extender cuff and Palmaz stent were placed before and failed	8 months	No (24mm shrinkage)	No
5	Henrikson et al.¹¹	1	Endovascular	Onxy injection through microcatheter from ipsilateral groin		18 months	Infrarenal aortic rupture for type Ib EL from right iliac limb for proximal migration	Coiling of right internal iliac artery and stentgraft extension into the external iliac artery
6	Naughton et al.¹²	12	Endovascular: 12	Internal iliac embolization and iliac limb extension: 6Stentgraft relining (associated with type Ia endoleak): 2Stentgraft relining (associated with type Ia and III endoleak): 1Stentgraft relining: 1Bilateral iliac limb extension: 1Iliac limb extension: 1		ns: 103 weeks from EL correction: 11 month from EL correction: 1	No: 8• 3 years later rupture sac aneurysm for type Ia endoleak treated with 3 aortic cuffs and aortic Palmaz stent; 1 year later: bilateral iliac limb extension for bilateral type Ib endoleak; then Onyx and coil embolization for residual type Ia endoleak• Urosepsis, multi organ failure and death• Tracheostomy and acute renal failure• Rupture for type Ia endoleak, urgent open conversion and intraoperative death
7	Ahn et al¹³	1	Endovascular	Balloon-expandable stent (Palmaz XL on 16 mm Maxi Balloon Cordis)		1 month	No	No
8	Faccenna et al.¹⁴	1	Endovascular	Right aorto-uni-iliac Zenith Cook endograft (from left transaxillary access and right femoral access) + endovascular plug in left common iliac artery + femoro-femoral crossover bypass graft		6 months	No	No
9	Chun and Morgan¹⁵	1	Endovascular	Onyx embolization	Distal endograft limb extension was not feasible for presence of visceral bypass grafts	10 months	No	No
10	Kordzadeh et al.¹⁶	1	Open (emergency)	Aorto-bi-iliac bypass graft (end-to-end technique to the proximal aorta, to the remaining right endograft limb and to the left native bifurcation of common iliac artery)		6 months	No	No
11	Vourliotakis et al.¹⁷	1	Endovascular	Zenith branched graft (Cook)		6 weeks	No	No

EL: endoleak; n-BCA: n-Butyl 2 cyanoacrylate; ns: not specified.

After repair of IbEL, buttock claudication occurred in two cases (6.7%) (after one coil embolization of the internal iliac artery followed by stentgraft extension, and one bypass graft from the leaking endograft to the external iliac artery associated with ligation of the internal iliac artery). Both cases of buttock claudication were reported as mild, and in one case the maximal walking distance improved after six months.

Early mortality (<1 month after endoleak treatment) occurred in two cases (3.4%): one after urgent open conversion for type Ia endoleak, the second for urosepsis followed by multiorgan failure three weeks after endovascular treatment of IbEL.

Follow-up

The follow-up specifications are reported in Table 3. The length of follow-up after IbEL treatment was reported in 14 cases (46.7%) (median: six months; interquartile range: 2.75–14; range: 0.75–53).

Type IbEL persisted or reappeared in three cases (10%) after endovascular treatment (one embolization with n-BCA, one embolization with Onyx, one internal iliac embolization and extender cuff deployment). Two of these (2/3, 66.7%) underwent reintervention (the first with coil embolization of the internal iliac artery and subsequent endograft extension, the latter with an adjunctive iliac extension).

No additional deaths during follow-up were reported.

Discussion

The current systematic review includes 11 publications considering 29 patients with 30 IbEL after aorto-iliac endografting. To date, scientific literature about this specific topic is very scant.

The analysis of the specific literature suggests that a type IbEL may occur essentially for two different causes: (i) an error during planning, or a technical inaccuracy during the procedure (e.g. insufficient endograft oversize, short sealing zone) or (ii) a progression of the aneurysmal disease.

During the preoperative planning, the measurements of iliac diameters, lengths, and the correct choice of suitable endograft components are essential to secure a durable distal sealing zone. Normally, an endoleak due to a planning error appears early after EVAR.¹⁸ During the follow-up, the progression of the aneurysmal disease in the aorta and iliac arteries leads to dilatation of iliac sealing zones, which may favor type IbEL some years after intervention. Considering data from the current literature review, diagnosis of IbEL was intraoperative in about 20% (6/28), within six months in about 30% (8/28) and after six months from endograft implant in half of the cases (14/28).

The length and the diameter of the distal sealing zone are crucial for IbEL prevention. A length of at least 10 mm is recommended by most endograft instruction for use (Cook Zenith Alpha: >10 mm¹⁹; Endurant II: ≥15 mm²⁰; Gore Excluder: ≥10 mm²¹; Anaconda ≥20 mm²²). The exploitation of the longest available iliac landing zone seems to be the most effective method to prevent endograft bending and/or dislocation. The distal edge of the endograft should be deployed as close as possible to the hypogastric ostium, in order to obtain the maximum sealing length of common iliac artery. Considering the sealing zone diameter, an oversizing >15% is reported as recommended to prevent distal complication.²³ Kaladji et al.²⁴ reported a statistical significant increase of the common iliac artery diameter within two years after endograft deployment. However, the radial force and hemodynamic constraints of the endograft are not sufficient to explain such described iliac artery dilatation.²⁴

Iliac endografts with a diameter >24 mm (e.g. in case of bell-bottom technique) are associated with an increased risk of IbEL during mid-term follow-up^25,26 and seems to be related with limb retraction at five years.²⁷

The angulation of iliac axis seems to play a role in type IbEL. Coulston et al.⁵ reported that 33 iliac limbs with iliac complications (IbEL, dislocation, insufficient engagement, occlusion, and kinks) were associated with higher tortuosity index when compared with 240 not-complicated limbs. In this experience, no statistical significant difference was found between the three types of implanted endograft devices (Zenith Flex (Cook Medical, Bloomington, IN), Endurant II (Medtronic, Minneapolis, MN), and Excluder (W. L. Gore and Associates, Flagstaff, AZ)). In our opinion, the tortuosity may be considered as an indicator of iliac limb complication, even if further studies are necessary to find possible correlation with co-factors (diameter, length, thrombosis, calcification) and IbEL.

Also, an AAA with ≥65 mm diameter seems to be related with a higher risk of IbEL.²³ In fact, in this systematic review, the size of the AAA is reported in 7/29 cases (24%), and the diameter exceeds 65 mm in 5/7 cases (71%).

Focusing on endograft, about half of IbEL developed in “old generation” devices. Many of these endografts are actually out-of-commerce (e.g. Ancure, Guidant, Indianapolis, IN; AneuRx, Medtronic/AVE Inc., Santa Rosa, CA). It is likely that technology development and devices innovation led to a reduction of complication rate, including IbEL.

The treatment of an IbEL is generally considered easier in comparison with type Ia endoleak. The deployment of a distal endograft extension is a minimally invasive, simple, and quick procedure and, in case of uncovered and not-dilated common iliac artery, it generally repairs the endoleak. In case of unavailability of an adequate distal neck in the common iliac artery, an endograft extension into the external iliac artery is necessary in most cases. The embolization of the hypogastric artery is possible and its necessity should be considered according to the risk of type II endoleak (size and angulation of hypogastric artery, diameter of iliac bifurcation). Considering the current review, seven cases of IbEL were treated with endograft extension and concomitant hypogastric artery embolization. In one case (14%, 1/7), a buttock claudication, defined as minor, was reported. After distal endograft extension and hypogastric embolization, a reintervention for recurrent IbEL occurred in one case (6%, 1/17).

Also the embolization of IbEL without distal endograft extension has been reported in literature (27%, 8/30). In these cases, different and sometimes multiple materials were placed to cover the endoleak site (e.g. n-BCA, Onyx (ev3 Inc., Irvine, CA)). Two of these patients (25%, 2/8) presented a persistent IbEL during follow-up. Data are scarce, but in our opinion, the sole embolization is not as effective as the distal endograft extension. The reason is that, even if technical success may be achieved during the procedure, an unhealthy iliac artery may dilate over time and the IbEL may reappear. Thus, an adequate distal neck is of vital importance to reduce the risk of IbEL recurrence.

Despite the potential limitations related to the fact that the cases of IbEL reported in non-specific literature (i.e. large case series, where different types of endoleak could not be distinguished) were not included in the analysis, and data about clinical presentation, anatomical characteristics, and follow-up are limited, the current systematic review is the sole study analyzing specifically type IbEL, paving the way for future randomized trials.

Conclusion

To date, specific literature about iliac type IbEL after aorto-iliac endografting for AAA is scant. About 50% of IbEL occurred after six months from the EVAR procedure. Anatomical characteristics such as the length and the diameter of the iliac sealing zone and the tortuosity of the iliac axes seem to play an important role in endoleak formation. These complications are typically managed by endovascular means, and the distal endograft extension (with or without hypogastric embolization) is the most frequent and effective treatment which has been reported in literature.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

White

May

Waugh

et al.

Type I and type II endoleaks: a more useful classification for reporting results of endoluminal AAA repair. J Endovasc Surg 1998; 5: 189–191.

Chaikof

Brewster

Dalman

et al.

SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg 2009; 50: 880–896.

Antoniou

Georgiadis

Antoniou

et al.

Late rupture of abdominal aortic aneurysm after previous endovascular repair: a systematic review and meta-analysis. J Endovasc Ther 2015; 22: 734–744.

McDonnell

Semmens

Allen

et al.

Large iliac arteries: a high-risk group for endovascular aortic aneurysm repair. J Endovasc Ther 2007; 14: 625–629.

Coulston

Baigent

Selvachandran

et al.

The impact of endovascular aneurysm repair on aortoiliac tortuosity and its use as a predictor of iliac limb complications. J Vasc Surg 2014; 60: 585–589.

Moher

Liberati

Tetzlaff

et al.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535.

Maldonado

Rosen

Rockman

et al.

Initial successful management of type I endoleak after endovascular aortic aneurysm repair with n-butyl cyanoacrylate adhesive. J Vasc Surg 2003; 38: 664–670.

Pereira

da Costa

de Souza

et al.

Minimally invasive surgical solution in the treatment of an unusual distal type I endoleak after endovascular abdominal aortic aneurysm repair. Vascular 2005; 13: 362–364.

Keo

Diehm

Baumgartner

et al.

Disseminated intravascular coagulopathy caused by endoleak type I: successful treatment by endovascular stent-graft extension. EJVES Extra 2006; 12: 68–70.

10.

Choi

Lee

et al.

Treatment of type I endoleaks after endovascular aneurysm repair of infrarenal abdominal aortic aneurysm: usefulness of N-butyl cyanoacrylate embolization in cases of failed secondary endovascular intervention. J Vasc Interv Radiol 2011; 22: 155–162.

11.

Henrikson

Roos

H and

Falkenberg

Ethylene vinyl alcohol copolymer (Onyx) to seal type 1 endoleak. A new technique. Vascular 2011; 19: 77–81.

12.

Naughton

Garcia-Toca

Rodriguez

et al.

Endovascular treatment of delayed type 1 and 3 endoleaks. Cardiovasc Intervent Radiol 2011; 34: 751–757.

13.

Ahn

Kim

Jeon

et al.

Successful treatment of type I endoleak of common iliac artery with balloon expandable stent (Palmaz XL stent) during endovascular aneurysm repair. J Korean Surg Soc 2012; 82: 59–62.

14.

Faccenna

Bresadola

Alunno

et al.

Type IB and type III endoleak 8 years after endovascular aneurysm repair. J Vasc Surg 2012; 55: 848..

15.

Chun

JY and

Morgan

Transcatheter embolisation of type 1 endoleaks after endovascular aortic aneurysm repair with Onyx: when no other treatment option is feasible. Eur J Vasc Endovasc Surg 2013; 45: 141–144.

16.

Kordzadeh

Scott

Railton

et al.

Aneurysmal degeneration and type Ib endoleak with proximal aneurysm rupture: a case report, review of literature and technical suggestions. Ann Med Surg 2014; 3: 43–46.

17.

Vourliotakis

Theodoridis

Pikis

et al.

Endovascular treatment of type Ib endoleak after Evar using the IBD device: a case report. Ann Vasc Dis 2016; 9: 209–212.

18.

Jasinski

Adrahtas

Monastiriotis

et al.

Early and late endograft limb proximal migration with resulting type 1b endoleak following an EVAR for ruptured AAA. Case Rep Vasc Med. 2017; 2017: 4931282. doi: 10.1155/2017/4931282.

19.

www.cookmedical.com/data/IFU_PDF/T_ZALPHA_REV2.PDF (accessed 2 August 2017).

20.

http://manuals.medtronic.com/manuals/main/region PDF (accessed 2 August 2017).

21.

www.goremedical.com/products/excludereu-ifu/instructions?locale=mpd_euro PDF (accessed 2 August 2017).

22.

www.vascutek.com/Downloads/IFUs/Anaconda/301-130_2%20Anaconda%20full%20language%20IFU.pdf PDF (accessed 2 August 2017).

23.

Bastos Gonçalves

Oliveira

Josee van Rijn

et al. Iliac seal zone dynamics and clinical consequences after endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2017; 53: 185–192.

24.

Kaladji

Cardon

Laviolle

et al.

Evolution of the upper and lower landing site after endovascular aortic aneurysm repair. J Vasc Surg 2012; 55: 24–32.

25.

Hobo

Sybrandy

Harris

et al. ; EUROSTAR Collaborators. Endovascular repair of abdominal aortic aneurysms with concomitant common iliac artery aneurysm: outcome analysis of the EUROSTAR Experience. J Endovasc Ther 2008; 15: 12–22.

26.

Albertini

Favre

Bouziane

et al.

Aneurysmal extension to the iliac bifurcation increases the risk of complications and secondary procedures after endovascular repair of abdominal aortic aneurysms. Ann Vasc Surg 2010; 24: 663–669.

27.

Waasdorp

Gorrepati

Rafii

et al.

Sideways displacement of the endograft within the aneurysm sac is associated with late adverse events after endovascular aneurysm repair. J Vasc Surg 2012; 55: 947–955.