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.
The patient was an 83-year-old man with a surgical history of aortic valve replacement and coronary artery bypass surgery who had been taking anticoagulants (apixaban) and beta-blockers (bisoprolol) since said surgery. He was diagnosed with oropharyngeal cancer at another medical facility, and computed tomography (CT) was performed for further generalized testing, which indicated an AAA (76 mm) and right internal iliac aneurysm (IIA); EVAR (Endurant II®, Medtronic Inc., Santa Rosa, CA, USA) and right IIA coil embolization were performed in the same year. The operation was completed with aortography showing no EL immediately after the procedure. On the follow-up CT, the aneurysm diameter enlarged, but no overt EL was indicated on repeat examination and testing with ultrasound, contrast-enhanced CT, and aortography.\nFour years after EVAR, the aneurysm diameter enlarged to 100×94 mm. Type II EL was suspected, and treatment intervention was planned. Embolization was performed on the root of the inferior mesenteric artery via the superior mesenteric artery using a metal coil and n-butyl-2-cyanoacrylate (NBCA) diluted 4-fold with lipiodol. In addition, 4-fold-diluted NBCA was similarly used to perform embolization of the vasa vasorum, imaged from the lumbar artery via the lateral sacral artery (). However, the aneurysm diameter increased further after these treatments. Magnetic resonance imaging showed uniform high-signal intensity inside the aneurysm on both T1- and T2-weighted images. Thus, the contents of the aneurysm were judged to be hematoma, and direct fine-needle aspiration was performed 5 years after EVAR. A total of 320 mL of dark-red and serous liquid was aspirated from inside the aneurysm (); the main blood component of the aspirated liquid was red blood cells. In addition, a pigtail catheter was inserted inside the aneurysm, and contrast-enhanced imaging was performed. However, the blood vessels that branched from the aneurysm were not shown on the images. The aneurysm diameter decreased temporarily as a result of fine-needle aspiration, but 8 months later, it increased again to its previous size. The likelihood of type II EL was considered to be low, considering the course of treatment up to this time. Also, because the contents of the aneurysm were uniform blood components, perigraft seroma was ruled out. Type Ia or III EL was believed to be possible, a shepherd-hook-type catheter was hooked onto the top edge of the central side of the stent graft, and aortography was repeated around the entire area. However, the images showed no EL, and type Ia was ruled out. Next, contrast-enhanced imaging was performed on the joining part from inside the legs, but it also showed no EL, and type IIIa was ruled out. Without being able to completely rule out type IIIb, an aortic cuff and stent-graft leg (GORE® Excluder®, W. L. Gore & Associates, Flagstaff, AZ, USA) were combined as a diagnostic treatment, and the stent graft that was initially inserted was covered around its entire circumference (). In a subsequent follow-up, a slight decrease in the aneurysm diameter was found.