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.
An 85-year-old man with hypertension, stroke, and severe asthma underwent EVAR with the Endurant II® endograft (Medtronic, Santa Rosa, CA, USA) and right internal iliac coiling for the treatment of a 67-mm infrarenal AAA and a 23-mm internal iliac aneurysm at the other hospital. EVAR had terminated with no sign of endoleak by completion angiography. Non-enhanced computed tomographic (CT) scan during yearly outpatient follow-up also showed no progressive dilatation of the aneurysm ().\nAbout 6 years later, however, CT scan showed rapid dilatation of the aneurysm with the diameter from 60 to 75 mm in a year. The contrast medium was filled inside the aneurysmal sac, suggesting the presence of type IIIa endoleak (). We planned an elective open surgery to treat the endoleak. Unfortunately, sudden abdominal pain and loss of consciousness occurred, and urgent CT showed ruptured AAA (). He underwent emergency open surgery.\nWe made a median laparotomy and found retroperitoneal hematoma with small amount of bloody ascites. Epiaortic echo showed no blood flow within the aneurysm. We punctured the aneurysm with an 18-gauge needle to measure the intra-aneurysmal pressure, which showed approximately 25 mmHg with no pulsatile flow. We assumed that there was no substantial blood flow into the aneurysm through the endoleak. The aneurysm was incised with a Teflon tape around the neck being pulled up without aortic clamp and heparin administration. When the mural thrombus was removed, active blood oozing from the fabric was observed on the left posterolateral side and just above the flow divider of the main body, which was considered to be type IIIb endoleak (). When traction of the tape around the aortic neck was loosened, blood flow was observed from the proximal side, which was type Ia endoleak. Type IIIb endoleak from the fabric was treated using a Teflon felt strip (15 mm wide and 1.8 mm thick) being directly wrapped around the stent graft and tightly banded (). Proximal aortic neck was also banded with the same felt strip as the treatment for type Ia endoleak (). Aortic wall was tightly sutured to cover the stent graft. The operation time was 260 min.\nPostoperative enhanced CT scan revealed no endoleak and no further dilatation of the aneurysm. He was discharged home on postoperative day 29 without any aortic complications.