Type 2 endoleak (T2EL) is the most common complication after endovascular aneurysm repair (EVAR), occurring in 10%–25% of patients. Although many T2ELs follow a benign course, persistent T2EL is associated with sac expansion, secondary endoleaks, rupture, and aneurysm-related mortality. Endovascular treatment is indicated in cases of progressive sac growth and is broadly divided into the transarterial approach and the direct sac puncture approach—the latter encompassing transabdominal, translumbar, and transcaval routes. Each approach has distinct technical advantages and limitations, and selection should be tailored to the source vessel of the endoleak, sac location, surrounding anatomy, and patient-related factors. Coils, N-butyl cyanoacrylate, and ethylene vinyl alcohol copolymer (Onyx) constitute the principal embolic agents, with liquid embolics showing improved durability over coils alone in recent comparative studies. Prophylactic embolization of the inferior mesenteric artery, lumbar arteries, or the aneurysm sac during EVAR has recently emerged as a promising preventive strategy. This review summarizes the current approaches, embolic materials, prophylactic strategies, and clinical outcomes of T2EL management from the perspective of the interventional radiologist.
