International multicenter experience on early and late outcomes after endovascular repair of ruptured abdominal aortic aneurysms in patients with vs without type II endoleaks

Background: Ruptured abdominal aortic aneurysms (rAAAs) remain as a great clinical challenge for vascular surgeons and endovascular aortic repair (EVAR), which is currently regarded as the first-line treatment for rAAA in patients with appropriate anatomy. While recommendations for management of type II endoleaks (T2ELs) are well-established in the elective setting, data after rAAAs are limited. Methods: Between January 2018 and December 2022, all patients who were treated with EVAR for rAAA in three tertiary referral centers from different countries (Germany, Italy, and Switzerland) were screened for inclusion in the study. The patients were divided into two groups based on the presence or absence of early T2EL (at completion angiography or at first postoperative computed tomography angiography). The primary end points for this study were 30-day mortality and long-term survival. Results: Overall, 123 patients were included in the final analysis. Of these, 73 were categorized as not having an early T2EL (group A) and 50 presented an early T2EL (group B). Except for a significantly lower proportion of males in group A as compared with group B (79.5% vs 92%; P = .05), no significant baseline differences were found. At 30 days, the overall mortality rate was not significantly different between study groups (22% vs 16%; P = .16). Using binary regression, the presence of a T2EL was not associated independently with 30-day mortality (odds ratio, 1.712; 95% confidence interval, 0.591-3.964; P = .54). Five-year survival estimates in the whole study cohort did not show any significant difference in patients without a T2EL as compared to those with a T2EL (53% vs 59%; log-rank P = .31). Using Cox proportional hazard regression, the presence of T2ELs was not independently associated with increased risk for long-term mortality (hazard ratio. 1.068; 95% confidence interval, 0.437-2.611; P = .079). Conclusions: Although the occurrence of a T2EL seems to be a relatively common scenario after EVAR for rAAA, their presence does not seem to be associated with worse outcomes in the immediate perioperative period or to decrease long-term survival. Therefore, careful observation may be warranted in the early phase, with selective treatment only in cases of ongoing hemodynamic decompensation. In the long run, it seems prudent to assume that the same indication for treatment as for standard EVAR could be recommended in the presence of T2EL.