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.
An 81-year-old man underwent EVAR for the treatment of a 70 mm AAA with deployment of 36 × 16 × 166 mm main body Endurant bifurcated endograft, 16 × 20 × 120 mm contralateral limb, and extensions of 16 × 16 × 95 mm to the right and to 20 × 20 × 80 mm to the left. His medical history included heart failure with an ejection fraction of 25%, hypertension, chronic obstructive pulmonary disease, and chronic renal failure requiring hemodialysis. He has been followed up regularly with Doppler ultrasonography and computerized tomography (CT) angiography at 3, 6, and 12 months showed successful exclusion of the aneurysm sac with no leak. Bilateral internal iliac arteries were patent (Figures and ).\nAbout 14 months after EVAR, the patient was admitted to the emergency clinic with sudden onset back pain. Clinical examination revealed a pulsatile mass at the epigastrium. Computerized tomography showed enlarged AAA bounded with hematoma and an endoleak originating from distal main body of the EVAR graft ().\nThe patient was taken to the angiography unit in the emergency night conditions. Several angiography runs were performed to determine the location of the endoleak; type 1a endoleak was excluded. The pigtail catheter was pulled into the main body. Angiogram showed endoleak at the level of the bifurcation endograft (). This time a type 3a endoleak (disconnection of main graft components) was suspected and 16 × 20 × 120 mm stent graft was placed from the contralateral limb. Control angiogram showed persistent endoleak; however, this time a type 3b endoleak was suspected.\nWe discussed the treatment options with the cardiovascular surgeons and we decided to treat the patient endovascularly because of the high mortality risk of the surgery. Endovascular options for the treatment included placement of a new aorto-uni-iliac or bi-iliac stent graft or coil embolization of the sac through translumbar or transarterial approach. We decided to deploy an aorto-uni-iliac stent graft, as there was not enough distance to deploy an aorto-bi-iliac graft between the bifurcation of the previous endograft and ostia of the renal arteries. In addition, we lacked enough and appropriate sized coils for the embolization of the sac in the night conditions. We deployed an Endurant uni-iliac stent graft with a body diameter of 36 mm (36 × 14 × 105 mm, Endurant, Medtronic Endovascular, Santa Rosa, Calif., USA). The control angiogram showed persistent endoleak despite additional ballooning. The antegrade flow was still present into the right limb decoding incomplete apposition of the latter stent graft to the previous one. The patient was clinically stable and there was no marked filling into the aneurysm sac so we decided to end the procedure and evaluate the filling of the right limb with a postoperative CT examination.\nThe second day CT angiography showed inaccurate apposition of the new stent graft into the previous stent graft because of the inadequate diameter of the aorto-uni-iliac stent graft; 36 mm is the largest diameter in the market. The gap between the stent grafts allowed persistent blood flow into the right limb and into the aneurysm sac through the fabric tear.\nWe decided to coil-embolize the fabric tear and aneurysm sac through the gap between the two-stent grafts after providing the appropriate coils sizes. The gap was catheterized with 5 F vertebral catheter rather than a 2.7 F microcatheter inserted into the aneurysm sac through the fabric tear (). We coiled the aneurismal sac with detachable coils until the angiography showed the complete disappearance of type 3b endoleak (). Control CT examination denoted no contrast filling into the sac; there was peripheral high-density area in the sac, which could be related to fresh clot or residual contrast media during coils embolization (). Doppler ultrasonography also confirmed no filling in the sac.\nThe procedure was terminated and the patient was transferred to the intensive care unit. Unfortunately, the patient was lost due to severe heart failure 72 hours after the second procedure.