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.
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.