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.
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.