Investigation of imaging predictors of endoleak in endovascular treatment of infrarenal abdominal aortic aneurysm

Background: Infrarenal abdominal aortic aneurysm (AAA) is the most common type of aortic aneurysm, frequently occurring in elderly patients with cardiovascular risk factors. The recommended treatment threshold is ≥ 5.5 cm in men and ≥ 5.0 cm in women. Open surgical repair was traditionally considered the standard approach but carries substantial risks. Since the 1980s, endovascular aneurysm repair (EVAR) has emerged as a less invasive alternative and has become increasingly common, reducing early mortality and hospital stay. However, one of the major complications after EVAR is endoleak, particularly type II. Therefore, identifying preoperative imaging predictors of endoleak is of great clinical importance for optimizing treatment and follow-up after EVAR. Objective: To investigate imaging characteristics that predict endoleak in patients with infrarenal abdominal aortic aneurysm treated with EVAR. Materials and Methods: A retrospective case series was conducted on 86 patients diagnosed with infrarenal AAA by clinical assessment and computed tomography angiography (CTA), who underwent EVAR at the Department of Vascular Surgery, Cho Ray Hospital from January 2022 to December 2024. Results: A total of 86 patients were included. The mean age was 73.1 years, with males accounting for 81.4%. The most common comorbidity was hypertension (96.51%), followed by dyslipidemia and coronary artery disease. Endoleak occurred in 5 cases of type IA (5.81%), 1 case of type IB (1.16%), and 22 cases of type II (25.6%). Adverse aneurysm neck anatomy (shorter length, larger diameter, greater angulation) was observed in patients with type IA endoleak. Univariate logistic regression showed that a patent inferior mesenteric artery (IMA) and IMA diameter ≥ 3 mm were strongly associated with type II endoleak (T2EL), while a higher number of patent lumbar arteries also tended to increase the risk. Multivariate logistic regression demonstrated that IMA diameter and the number of patent lumbar arteries were independent predictors of T2EL (OR: 2.63, p = 0.026; OR: 2.71, p = 0.019). Conclusion: Patients with high-risk anatomical features (IMA diameter ≥ 3 mm and/or ≥ 3 patent lumbar arteries) have a significantly higher risk of developing T2EL compared with those without such features.