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 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.