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 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.