# A Systematic Review and Meta-Analysis of Laparoscopic Ligation of the Inferior Mesenteric Artery for the Treatment of Type II Endoleaks

## TL;DR

This study reviews laparoscopic IMA ligation as a treatment for Type II endoleaks after aortic aneurysm repair, finding it safe but needing more research to confirm effectiveness.

## Contribution

The paper provides a systematic review and meta-analysis of laparoscopic IMA ligation for Type II endoleaks, evaluating its safety and feasibility.

## Key findings

- Laparoscopic IMA ligation showed 100% technical success and 0% postoperative mortality in pooled results.
- Reintervention rates were 15.08%, but results were underpowered for definitive conclusions.
- Proper classification of T2E types is critical for treatment outcomes.

## Abstract

Type II endoleak (T2E), often generated by persistent
retrograde flow through the inferior mesenteric artery (IMA) is the most frequent
complication following endovascular aortic aneurysm repair (EVAR). T2E treatment
revolves around transarterial and translumbar embolization of the feeding artery
and/or sac, with mediocre results. The aim of this study is to assess the safety
feasibility and efficacy of laparoscopic IMA ligation for the treatment of T2E.

We conducted a systematic electronic research on Medline,
Scopus, EMBASE, and Cochrane Library according to Preferred Reporting Items for
Systematic Review and Meta-Analysis protocol (PRISMA) for articles published up
to February 2022, describing laparoscopic IMA ligation for the treatment of T2E.
Publications describing hand assisted or prophylactic IMA ligation were excluded.
A metanalysis was performed utilizing both the random and common effects model
and the DerSimonian and Laird method. Additionally, we carried out a post hoc
power analysis.

Fifteen studies, including one prospective case
series (CS), five retrospective CS and nine case reports, including 33 patients
(91% male) met the inclusion criteria. The mean abdominal aortic aneurysm
diameter at the time of diagnosis was 58.8 mm. The mean operational duration was
117.5 minutes. The mean follow-up for the included studies was 17 months. The
mean reported time of T2E identification was 9.1 months post-intervention, while
the mean reported aneurysmal sac diameter increase at the time of diagnosis was
11.5 mm. T2E type a (T2aE) and type b (T2bE) patterns were 57.6% and 42.4%
respectively. Six CS incorporating 24 patients were included in the
meta-analysis. The pooled technical success and postoperative mortality rates are
100% (95% CI: 93.13–100), (I2 = 0.0%, p = 0.99) (power = 99%)
and 0.00% (95% CI: 0.00–6.87) (I2 = 0.0%, p = 0.99). The pooled
reintervention and conversion to open surgical repair rates are 15.08% (95% CI:
0.79–37.28), (I2 = 0.0%, p = 0.66) (power = 13.6%), and 0.69%
(95% CI: 0.00–14.80) (I2 = 0.0%, p = 0.99) (power = 7.05%)
respectively.

We demonstrated the safety and feasibility of
IMA ligation for the treatment of T2E. Definitive conclusions about its efficacy
cannot be drawn due to underpowered results warrantying further research.
Identification and proper classification of T2E remain an obstacle affecting
treatment outcomes and reintervention rates throughout the entire spectrum of
available treatments.