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.
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.