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 eighty-one-year-old male visited the clinic complaining of abdominal pain along with pulsating mass. He had been diagnosed with infrarenal aortic aneurysm and this was treated with EVAR 6 years previously. After EVAR, a gradual increasing of the aneurysm sac was found without evidence of any type of endoleak. Eventually, the aneurysm reached a diameter of 9.7 cm on the computed tomography (CT) angiography and abdominal pain redeveloped. CT angiography showed a huge aortic aneurysm without evidence of endoleak, and it was considered that this was due to endotension.\nCT-guided sac aspiration was performed through the translumbar puncture of the aneurysm sac, and 400 mL of a dark brown-colored liquid was aspirated (). CT scan was performed the day after the puncture and the sac shrunk back to its original size (). Abdominal pain subsided and the palpating mass disappeared. One month after the aspiration, a CT scan was retaken, and the scan showed that the aneurysm sac increased back to the size before the aspiration (). Additionally, the scan showed no signs of endoleak. A second aspiration was performed again, and a further 300 mL of the dark brown colored fluid was aspirated. During the second aspiration, small amounts of contrast media was administered through the lumbar puncture site in order to search for the presence of collateral flow induced endoleak and to detect any possible rupture of the aneurysm sac. But no contrast media leakage from the sac was found, and no endoleak was found. So it was concluded that the increase of the aneurismal sac was due to endotension.\nFinally, with the consent of the patient, the endovascular relining technique was performed on the patient to treat the endotension. Since the diameter of the main body of the original endograft was 28 mm, it was planned that the relining process would be carried out by inserting two customized, tubular stent-grafts each of 14 mm in diameter. The length of the relining stent-graft was calculated to cover not only the whole length of the original stent-graft but to cover the entire growing sac. The patient was put under general anesthesia, and both common femoral arteries were punctured and selection of both limbs of the original stent-graft was attempted. Unexpectedly, the guide wire escaped from the junction area of the left module to the aneurysm sac. Upon inspection, a modular disconnection was found at the left graft junction area resulting in large amounts of leakage from the disconnected area. The original main body was selected with difficulty, and two 14-mm- × 12-cm-sized stent-grafts were successfully implanted within the original endograft (). Ancillary attachment between the original and the new stent-grafts was made with a compliant balloon. A final aortogram was performed and no endoleak was detected and the leakage from the modular disconnection disappeared after the endovascular relining. The day after the procedure, CT angiography showed no endoleak but retroperitoneal hematoma around the aneurysm sac was found. It was determined that the contained aneurismal sac rupture and the retroperitoneal hematoma were caused by the leakage from the modular disconnection.\nSerial review of the plain x-rays taken since the initial EVAR 6 years prior showed very subtle but gradual modular migration unnoticeable by eye, and complete disconnection developed within 5 days between the day of the second aspiration and the relining procedure. It was determined that the modular disconnection was a result of the aspiration (). The patient showed no symptoms or signs of aneurysm sac rupture after the procedure and was discharged with no further complications. CT scan taken four months after the relining procedure showed no endoleak and the size of the aneurysm sac decreased from 9.7 to 9.3 cm.