Have you ever heard of an `Aneurysm`, a condition in which the wall of the aorta or a large blood vessel in the body becomes weak and bulges like a balloon? Maybe you have had one, and doctors have treated it by inserting a small tube called a `Stent Graft`, which is a procedure called `Endovascular`, which means without making a big incision. Think of it like a leak in an old water pipe. So doctors put another tube inside the leak to strengthen it. However, sometimes after that treatment, a little blood starts to leak out of the `Stent Graft`, into the sac where the `Aneurysm` used to be. That's what we call `Endoleak` in medicine. Today, we'll talk in a little more detail about what this really is, why it happens, is it dangerous, how to detect it, and what the treatments are.
What exactly is `Endoleak`?
Simply put, `Endoleak` means that after the `Aneurysm` has been treated and sealed, blood begins to flow again inside the old `Aneurysm` sac. Now, look, usually when an `Aneurysm` is treated, your blood only flows through the newly inserted `Stent Graft` tube. This `Stent Graft` is like a support for the weakened blood vessel wall. Therefore, blood does not flow to the damaged, bulging part of the blood vessel, that is, the `Aneurysm Sac`. Then the `Aneurysm` stops getting bigger and bursting. It should be okay if there is no bleeding.
However, if for some reason blood leaks outside the `Stent Graft` and into the `Aneurysm Sac`, that is called `Endoleak`. There are various reasons why this `Endoleak` occurs. Some of them are due to problems with the `Graft` itself, and some of them may be due to other small blood vessels starting from the `Aneurysm Sac`. It is like water leaking from some places after a roof is opened.
If an `Endoleak` occurs within 30 days of this `Endovascular` treatment, we call it ``early endoleaks`` . Those that develop after 30 days are called ``secondary endoleaks`` or ``late endoleaks`` .
How common is `Endoleak`?
Now you may be wondering if this `Endoleak` is something that happens to everyone or is something that happens rarely. In fact, this `Endoleak` condition can occur in about 1 in 4 people who undergo `Endovascular Aneurysm Repair` (we call it `EVAR` for short - this is a treatment mainly for `Aneurysm` in the abdominal wall) or `Thoracic Endovascular Aneurysm Repair` (`TEVAR`) for `Aneurysm` in the chest . So, it is not that unheard of. That is why it is very important to be aware of this.
Is an `Endoleak` dangerous?
This may scare you a little. "Oh, I'm afraid it's going to bleed again, isn't it?" But not all endoleaks are dangerous . Some endoleaks don't cause any harm and get better on their own. Just like a small wound heals on its own. In such cases, your doctor may decide to just monitor your condition. This means continuing to do tests and see what happens.
However, some types of `Endoleak` are a bit more serious. To prevent the possibility of that `Aneurysm` getting bigger again and bursting, it needs to be treated quickly. Because if an `Aneurysm` bursts, it can be life-threatening. So, whether this is dangerous or not depends on the type of `Endoleak` and its location. Doctors make decisions based on all of these factors.
What types of `Endoleak` are there?
There are currently five types of `Endoleak` identified. Each type has a different cause. Just like each disease has its own cause. With the development of new `Stent Graft` technology, some types of `Endoleak` have now decreased a bit, which is a good thing.
Of these , `Type 2 Endoleak` is the most common . However , `Type 1` and `Type 3` endoleaks are a bit more dangerous , as they increase the risk of the `Aneurysm` bursting (`rupturing`). Let`s take a closer look at these types.
`Type 1 Endoleak`
This happens when the stent graft is not properly attached to the wall of the blood vessel, meaning it is not properly sealed. Imagine, if there is a small gap between the cover and the wall, water will leak from there, and blood will leak from either the upper end (proximal) or lower end (distal) of the stent graft and go into the aneurysm sac. Type 1 endoleak is a serious condition, so it usually requires immediate treatment. These are more likely to rupture the aneurysm than other types. If doctors see this, they will take action quickly.
`Type 2 Endoleak`
This is the most common type of endoleak . It is more common after EVAR than TEVAR for abdominal aneurysms. This leak occurs when blood leaks into the aneurysm sac through small blood vessels (branch vessels or collateral vessels) that branch from your aorta or the blood vessel that has the stent. Imagine that your large blood vessel (aorta) has small branches (branches). Now, even if we put a new tube (stent graft) to close the hole in the large blood vessel (aneurysm), some blood can still leak from those branches to the old hole. That is what Type 2 endoleak is like.
Most of the time, Type 2 Endoleaks are diagnosed within 30 days of your Endovascular treatment. However, they can sometimes occur later, known as "late endoleaks." About 40% of Type 2 Endoleaks are diagnosed after 30 days. About 8% are diagnosed after a year of treatment.
But most `Type 2 Endoleaks` are not that harmful . They get better on their own after about six months without any treatment. Because those small blood vessels close up on their own. Even if they don't get better, if the `Aneurysm Sac` is stable and not getting bigger, the doctor can keep an eye on it. But occasionally, over time, this `Type 2 Endoleak` can cause changes in the `Aneurysm Sac` and turn into a more dangerous `Endoleak` like `Type 1` or `Type 3`. If that happens, treatment is needed. If the `Aneurysm` is larger than 5 millimeters (`5mm`), you may need treatment. If the `Aneurysm` is left untreated, there is a chance that the `Aneurysm` will burst.
`Type 3 Endoleak`
A Type 3 Endoleak occurs when the overlapping modular components of your stent graft separate, or if the fabric of the graft itself tears or tears. This is similar to a pipe that separates at the joint, or a hole forms in the pipe itself. Like a Type 1 Endoleak, there is a risk of the aneurysm bursting because blood is flowing directly into the aneurysm sac under pressure. Therefore, prompt treatment is essential. However, with advances in device design, Type 3 Endoleaks are rare.
`Type 4 Endoleak`
This occurs when blood leaks through the tiny holes in the stent graft (the porosity of the graft material). This is usually seen early in the treatment, but often resolves on its own. This is a very rare complication of the graft, and is much less common with the grafts used today.
`Type 5 Endoleak`
`Type 5 Endoleak` is also called ``Endotension``. This is a bit strange. What happens in this case is that, even though there is no sign of ``Endoleak`` on ``Imaging`` tests, the ``Aneurysm Sac`` continues to grow. Although the exact cause of this is not clear, it is thought that there may be ``pressure transmission`` through the ``Stent Graft``, even though there is no visible blood leak. This is also a condition that needs to be monitored.
What are the symptoms of an `Endoleak`?
This is the problem that many people have. There are usually no symptoms that indicate you have an endoleak. You may not notice anything. An endoleak is detected by imaging tests on the day of your treatment and by follow-up tests. That is why it is very important to go to your follow-up tests regularly. By going to your doctor on the days that they tell you, you can quickly identify if something like this is happening.
However, if the aneurysm becomes larger and bursts (aneurysm ruptures) due to an endoleak (especially a dangerous type), it is a medical emergency . If this happens, the following symptoms may occur. If this happens , you should call 911 or go to the nearest hospital immediately :
- The body is cold and sweaty (`Clammy, sweaty skin`).
- Dizziness, a feeling of spinning in the head.
- Fainting, loss of consciousness.
- Heartbeat is getting faster (`Fast heartbeat`).
- Nausea and vomiting.
- Difficulty breathing, feeling like you're suffocating (shortness of breath).
- Sudden, severe pain in your belly, lower back or legs.
- Sudden sharp and tearing pain in your chest or back.
If these symptoms appear, don't delay.
How do you find an `Endoleak`?
As mentioned earlier, an endoleak is diagnosed through imaging tests. These tests are done during and after your endovascular aneurysm repair. Most of the time, it is diagnosed on the same day or within 30 days of the procedure. However, it can sometimes occur up to 12 months or even longer. That is why it is so important to keep all of your follow-up appointments. Just like servicing a car, this is something that needs to be taken care of on an ongoing basis.
Tests to detect `Endoleak`
The main tests used to diagnose `Endoleak` during and after treatment are:
- `Computed Tomography (CT) scans`: This takes cross-sectional images of the inside of the body. The `Stent Graft`, `Aneurysm Sac`, and blood leaks can be clearly seen.
- Doppler Ultrasound: This uses sound waves to look at the way blood flows. It can detect if there is an endoleak and how the blood is flowing.
- Angiogram: In this, a special liquid (contrast dye) is injected into the blood vessels and X-ray images are taken. Blood flow and leaks can be clearly seen.
These tests can help determine if your treatment is successful, if the stent graft is in place, and if there is any leakage around the stent.
You will need to have these `imaging` tests for months or years after treatment. Your doctor will tell you about these tests and how often you should have them. However, these tests are essential to catch any `endoleak` that may develop later (`secondary endoleaks`) quickly and treat it if necessary.
What are the treatments for `Endoleak`?
Your medical team will treat your Endoleak according to your individual needs. The way Endoleak is managed is different for each person. This will depend on your body type (for example, the length of your aneurysm's neck, the location of the blood vessels, etc.), the type of Endoleak, and its location. In general, there are three main options for treating Endoleak: observation, endovascular treatment, and/or open surgery.
Observation
If you have a less serious type of endoleak, such as a Type 2 endoleak, your doctor may recommend a "watchful waiting" approach to see if it will heal on its own. This can happen if the connecting blood vessels clot (clot off), stopping the blood flow to the aneurysm sac. However, if the endoleak causes the aneurysm sac to become larger (i.e., larger than 5 mm), you will need treatment to prevent it from rupturing.
Endovascular treatment
This is the most common treatment for an endovascular aneurysm. Your endovascular surgeon can perform an endovascular aneurysm repair using minimally invasive techniques. These may include:
- Blocking the branch blood vessels that supply blood to the aneurysm. That is, a special substance (embolizing agent) is injected into the small blood vessels that cause the Type 2 Endoleak and they are closed.
- A `Stent Graft` is a procedure that involves placing additional `Stent` pieces (`cuffs or extenders`) beyond the leak, extending the area of your large artery (`Aorta`) where the `Stent` was placed. This is often done for `Type 1 Endoleak`.
- Going directly to the aneurysm sac and sealing the aneurysm sac using glue-like materials.
These methods allow treatment to be performed without a large incision, through a small hole.
Surgery (`Open Surgery`)
If endovascular treatments are not possible or fail, open surgery is usually the last resort. This involves making a large incision, going into the aneurysm, and either repairing the stent graft or inserting a new one. This is very rare, as endovascular techniques are now much more advanced.
What to expect if you have an `endoleak`?
Most of the time, an Endoleak does not require treatment, especially Type 2. Even if treatment is needed, there are many minimally invasive options that require fewer incisions. These Endovascular treatments have shown very high success rates. In addition, new technologies are continuing to improve the use of stent grafts that reduce the risk of Endoleak.
If you have an endoleak, don't panic. Your doctor will explain your treatment options to you. The most important thing is that you will need to continue to have follow-up tests even after the endoleak has healed. This is very important so that if there are any future problems with your stent graft, they can be identified and treated quickly. It's like maintaining a car.
When should I see my doctor?
Be sure to keep all follow-up appointments after your EVAR or TEVAR treatment. Your doctor will tell you how often you need to have imaging tests. Usually, they will be closer together at first, but may become more frequent over time. Follow those instructions exactly.
Also, if you experience any of the emergency symptoms that come with a ruptured aneurysm, as mentioned earlier, go to a hospital immediately without waiting.
Questions to ask your doctor
After your EVAR or TEVAR procedure, ask your doctor about the risks of complications. Also, talk about follow-up tests and what imaging tests to expect. You can ask questions like:
- What are the possible side effects (complications) of this treatment? What is my risk of developing an endoleak?
- How often do I need to come for follow-up? What kind of tests (such as CT scan, ultrasound) will I need to have?
- What treatment options do I have if I develop an `endoleak`?
- What lifestyle changes can I make to help my heart health and keep my stent graft in good condition? (e.g., quitting smoking, exercising, diet)
It is very important to ask questions like these to gain a better understanding of your situation.
What is the message we can take home from this story?
Endoleak is a manageable complication that can occur after endovascular aneurysm repair. You may not need any treatment. However, if you do, your doctor will talk to you about the treatment options that are right for you.
It is common for complications like these to occur after a life-saving procedure, such as treating an aneurysm. However, the benefits of the procedure far outweigh the risks . So don't panic if you find out about an endoleak.
The most important thing is to go to the follow-up appointments that the doctor gives you and get the tests he recommends. That way, any problems can be identified and treated quickly.
If you feel tired and overwhelmed, it's normal. Many people are going through the same thing as you. Talk to your doctor and family about ways to manage the stress that comes with recovery. You're not alone.
` Endoleak, Aneurysm, Stent Graft, EVAR, TEVAR, Bleeding, Aneurysm, Stent Graft, Heart Disease
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