Long-Term Outcomes of Stent Relining for the Management of High-Pressure Endoleaks With Progressive Sac Expansion After Endovascular Aneurysm Repair (EVAR)

Background High-pressure endoleaks (Types I, III, and V) with progressive sac expansion remain a significant challenge following endovascular aortic repair (EVAR). Stent graft relining, with or without adjunctive procedures such as femoral crossover bypass, embolization, or chimney stents, has emerged as an important intervention. However, data on long-term outcomes remain limited. We evaluated the efficacy and durability of relining in this patient cohort. Methods We performed a retrospective analysis of all patients treated with EVAR stent relining for Type I, III, or V endoleaks with progressive sac growth (>5mm) at a regional vascular center between 2014 and 2024. Data included demographics, comorbidities, aneurysm characteristics, type of endoleak, mode of presentation, technical success, sac stabilization, reintervention rates, and survival outcomes. Results Seventy-nine patients had significant endoleaks, of whom 32 (40.5%) underwent relining (13 Type I, nine Type III, 10 Type V). Mean time to endoleak was 57 months. Technical success was 100%. Sac stabilization was achieved in 87.5% of patients at a mean follow-up of 48 months. The reintervention rate was 15.6%. Twenty-five patients (78%) were treated electively, while seven (22%) underwent emergency relining for rupture. There was no 30-day mortality in either group. At one year, survival was 100% in the elective group versus 71% in the emergency group (p=0.01), falling to 57% at two years (p=0.002). Emergency relining was associated with a 5.6-fold higher risk of sac stabilization failure compared with elective repair. Conclusion Stent relining is a highly effective treatment for high-pressure endoleaks with sac expansion, achieving excellent technical success and durable sac stabilization when performed electively. However, outcomes are significantly worse in emergency settings, with higher failure and mortality rates. These findings strongly support prioritizing elective relining for progressive endoleaks to optimize long-term outcomes.