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.
An eighty-one-year-old male visited the clinic complaining of abdominal pain along with pulsating mass. He had been diagnosed with infrarenal aortic aneurysm and this was treated with EVAR 6 years previously. After EVAR, a gradual increasing of the aneurysm sac was found without evidence of any type of endoleak. Eventually, the aneurysm reached a diameter of 9.7 cm on the computed tomography (CT) angiography and abdominal pain redeveloped. CT angiography showed a huge aortic aneurysm without evidence of endoleak, and it was considered that this was due to endotension.\nCT-guided sac aspiration was performed through the translumbar puncture of the aneurysm sac, and 400 mL of a dark brown-colored liquid was aspirated (). CT scan was performed the day after the puncture and the sac shrunk back to its original size (). Abdominal pain subsided and the palpating mass disappeared. One month after the aspiration, a CT scan was retaken, and the scan showed that the aneurysm sac increased back to the size before the aspiration (). Additionally, the scan showed no signs of endoleak. A second aspiration was performed again, and a further 300 mL of the dark brown colored fluid was aspirated. During the second aspiration, small amounts of contrast media was administered through the lumbar puncture site in order to search for the presence of collateral flow induced endoleak and to detect any possible rupture of the aneurysm sac. But no contrast media leakage from the sac was found, and no endoleak was found. So it was concluded that the increase of the aneurismal sac was due to endotension.\nFinally, with the consent of the patient, the endovascular relining technique was performed on the patient to treat the endotension. Since the diameter of the main body of the original endograft was 28 mm, it was planned that the relining process would be carried out by inserting two customized, tubular stent-grafts each of 14 mm in diameter. The length of the relining stent-graft was calculated to cover not only the whole length of the original stent-graft but to cover the entire growing sac. The patient was put under general anesthesia, and both common femoral arteries were punctured and selection of both limbs of the original stent-graft was attempted. Unexpectedly, the guide wire escaped from the junction area of the left module to the aneurysm sac. Upon inspection, a modular disconnection was found at the left graft junction area resulting in large amounts of leakage from the disconnected area. The original main body was selected with difficulty, and two 14-mm- × 12-cm-sized stent-grafts were successfully implanted within the original endograft (). Ancillary attachment between the original and the new stent-grafts was made with a compliant balloon. A final aortogram was performed and no endoleak was detected and the leakage from the modular disconnection disappeared after the endovascular relining. The day after the procedure, CT angiography showed no endoleak but retroperitoneal hematoma around the aneurysm sac was found. It was determined that the contained aneurismal sac rupture and the retroperitoneal hematoma were caused by the leakage from the modular disconnection.\nSerial review of the plain x-rays taken since the initial EVAR 6 years prior showed very subtle but gradual modular migration unnoticeable by eye, and complete disconnection developed within 5 days between the day of the second aspiration and the relining procedure. It was determined that the modular disconnection was a result of the aspiration (). The patient showed no symptoms or signs of aneurysm sac rupture after the procedure and was discharged with no further complications. CT scan taken four months after the relining procedure showed no endoleak and the size of the aneurysm sac decreased from 9.7 to 9.3 cm.