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.
The patient was an 83-year-old man with a surgical history of aortic valve replacement and coronary artery bypass surgery who had been taking anticoagulants (apixaban) and beta-blockers (bisoprolol) since said surgery. He was diagnosed with oropharyngeal cancer at another medical facility, and computed tomography (CT) was performed for further generalized testing, which indicated an AAA (76 mm) and right internal iliac aneurysm (IIA); EVAR (Endurant II®, Medtronic Inc., Santa Rosa, CA, USA) and right IIA coil embolization were performed in the same year. The operation was completed with aortography showing no EL immediately after the procedure. On the follow-up CT, the aneurysm diameter enlarged, but no overt EL was indicated on repeat examination and testing with ultrasound, contrast-enhanced CT, and aortography.\nFour years after EVAR, the aneurysm diameter enlarged to 100×94 mm. Type II EL was suspected, and treatment intervention was planned. Embolization was performed on the root of the inferior mesenteric artery via the superior mesenteric artery using a metal coil and n-butyl-2-cyanoacrylate (NBCA) diluted 4-fold with lipiodol. In addition, 4-fold-diluted NBCA was similarly used to perform embolization of the vasa vasorum, imaged from the lumbar artery via the lateral sacral artery (). However, the aneurysm diameter increased further after these treatments. Magnetic resonance imaging showed uniform high-signal intensity inside the aneurysm on both T1- and T2-weighted images. Thus, the contents of the aneurysm were judged to be hematoma, and direct fine-needle aspiration was performed 5 years after EVAR. A total of 320 mL of dark-red and serous liquid was aspirated from inside the aneurysm (); the main blood component of the aspirated liquid was red blood cells. In addition, a pigtail catheter was inserted inside the aneurysm, and contrast-enhanced imaging was performed. However, the blood vessels that branched from the aneurysm were not shown on the images. The aneurysm diameter decreased temporarily as a result of fine-needle aspiration, but 8 months later, it increased again to its previous size. The likelihood of type II EL was considered to be low, considering the course of treatment up to this time. Also, because the contents of the aneurysm were uniform blood components, perigraft seroma was ruled out. Type Ia or III EL was believed to be possible, a shepherd-hook-type catheter was hooked onto the top edge of the central side of the stent graft, and aortography was repeated around the entire area. However, the images showed no EL, and type Ia was ruled out. Next, contrast-enhanced imaging was performed on the joining part from inside the legs, but it also showed no EL, and type IIIa was ruled out. Without being able to completely rule out type IIIb, an aortic cuff and stent-graft leg (GORE® Excluder®, W. L. Gore & Associates, Flagstaff, AZ, USA) were combined as a diagnostic treatment, and the stent graft that was initially inserted was covered around its entire circumference (). In a subsequent follow-up, a slight decrease in the aneurysm diameter was found.