The patient is an 83-year-old gentleman who underwent elective EVAR for an asymptomatic 5.9 cm infrarenal AAA with a Medtronic Talent bifurcated stent graft (Medtronic, Dublin, Ireland) in 2008. The operation was performed successfully and uneventfully. The main body of the graft (30 mm × 20 mm × 140 mm) was deployed under fluoroscopic guidance via cannulation of the right femoral artery. The contralateral graft limb (14 mm × 18 mm × 19 mm) was deployed, along with a contralateral extension (20 mm × 20 mm × 79 mm). Finally, an ipsilateral extension (20 mm × 20 mm × 79 mm) was placed. Balloon dilation was performed of all junctions. Bilateral renal arteries and internal iliac arteries were patent. Completion angiogram revealed no Type 1 endoleak, with late filling of the sac secondary to Type II endoleak from the lumbar arteries (). There were no complications peri-operatively, and the Type II endoleak ceased on the 1-month follow-up computerized tomography (CT). Post-operatively, this patient was enrolled in our EVAR surveillance program where patients are followed up with CT scan at 1 month, 6 months and annually thereafter to assess for graft-related complications. CT scan at 2-year follow-up demonstrated sac regression with no endoleaks ().\nSeven years later in 2015, ultrasound revealed sudden expansion of his aneurysm sac from 5.2 to 8.0 cm within the 1-year scan. Based on initial surveillance ultrasound and subsequent CT scan, the source of endoleak was challenging to deduce; a Type 1a leak was initially suspected though stent migration or neck expansion was excluded (). Angiogram was then performed revealing Type IIIb endoleak arising from a tear in the distal main body or proximal left graft limb (). Given the rate of sac expansion, subsequent repair was urgently performed. Intraoperatively, we confirmed the Type III leak and its location at the distal main body by doing selective balloon occlusions and simultaneous angiograms. We treated this endoleak with an aortouniiliac endograft and femorofemoral artery bypass in order to cover the site of Type IIIb endoleak. The main body (Medtronic Endurant II aortouniiliac (36 mm × 14 mm)) was deployed within the previous Talent graft at the same level as this previous device, landing distally in the left common iliac artery. This was further extended into the left common iliac artery using an Endurant II iliac limb (16 mm × 20 mm × 93 mm) to successfully exclude the Type IIIb endoleak. A Talent occluder (20 mm) was placed in the right common iliac artery to prevent retrograde filling (). The patient recovered well and was discharged 2 days post-operatively.\nRepair of this significantly delayed Type IIIb endoleak was carried out successfully. Post-operative contrast-enhanced CT scan revealed no filling of the aneurysm sac, suggesting the endoleak has sealed itself off. Clinical follow-up has been unremarkable. This patient will continue to undergo EVAR imaging surveillance to detect future complications. Patient consent was obtained for this case report.
A 71-year-old male, who had been submitted to EVAR with a bifurcated Talent endoprosthesis in 2006 for a 5,5 cm AAA, was admitted to the emergency department reporting sudden onset of abdominal pain with lumbar radiation and a history of a brief loss of consciousness one hour earlier. He was found to be hypotensive and tachycardic (BP: 90/60 mmHg, Bpm: 110/min, RR: 22/min, and SpO2: 95%). Hgb level was significantly decreased (8,5 g/dl) and a pulsatile mass was prominent upon clinical examination. The patient's medical history included chronic obstructive pulmonary disease, myocardial infarction with heart failure, chronic renal failure, hypertension, and smoking. The high clinical suspicion of ruptured AAA was verified with CT scan. Contrast media had to be avoided due to severe renal failure. A leaking 9 cm AAA with a huge retroperitoneal hematoma was depicted (). The Talent stent-graft was migrated () and the proximal sealing was lost, leading to potential type I endoleak, sac enlargement, and rupture. At this point, no further information was available from the CT scan (unenhanced). Endoluminal reintervention was immediately scheduled with the use of a proximal aortic extension. The procedure was carried out in an operating room equipped with a portable C-arm (Siremobil 2000, Siemens, Erlangen, Germany) under local anesthesia. Bilateral femoral arteries were surgically exposed in standard fashion. Heparin (5000 IU) was administered intravenously. Initial angiography verified the hypothesis of migration and endoleak. The Talent was migrated 2 cm distally to the left (lower) renal artery, the proximal sealing was lost, and a huge type Ia endoleak was shown (). Based upon the CT measurements and the intraoperative data, a 28 mm in diameter × 60 mm in length Ankura (LifeTech, Inc., China) aortic extender with 15 mm bare stent was deployed () to bridge the proximal aortic neck (estimated 24 mm in diameter × 15 mm in length) with the migrated Talent body (26 mm in diameter × 50 mm in length tubular segment). Postdeployment angiography showed that the type Ia endoleak was sealed and the aortic extender was correctly placed just below the left renal artery. To our surprise, contrast media continued to be visible in a different fashion from the initial angiography outside the Talent endograft restricted at the level of its bifurcation (). When we inflated a molding balloon thinking that it was a leak in between the Ankura extender and the Talent body, a fabric tear became apparent near the stent-graft bifurcation () feeding the endoleak. The balloon was removed and a guide wire was meticulously passed through the fabric opening to verify the fabric tear and the type IIIb endoleak (). Two Ankura limbs, 16-16 × 100, were inserted and simultaneously deployed as parallel kissing endografts. The proximal 6 cm of the parallel endografts was positioned above the Talent bifurcation within the Ankura cuff and the distal 4 cm inside each Talent limb below the Talent bifurcation () to ensure adequate sealing of the fabric tear. Kissing balloon technique followed using two 14 × 40 PTA Atlas balloons (Bard Peripheral Vascular Inc., AZ, USA) inflated at 4 atm. Completion of DSA verified endoleak resolution, renal and iliac artery patency, and proper endograft deployment. The patient recovered fully and was released on the 7th postoperative day with no further renal deterioration and increased Hgb level (11,5 g/dl). The patient was readmitted in another hospital in the 40th postoperative day due to pulmonary edema. Ultimately he died due to heart failure and his death had no relation to the AAA. The report of this man's case was approved by the institutional review board.