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.
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.