Managing Type I and III Endoleaks Presenting on Separate Occasions in an Abdominal Aortic Aneurysm

Purpose: Endovascular aortic aneurysm repair (EVAR) has been performed for almost 30 years. With an increased number of procedures performed, it is important to understand managing complications. The different types of endoleaks are well established, but management and surveillance are variable and challenging.

Materials and Methods: We present a case of an 88-year-old man with a pertinent medical history of hypertension, coronary artery disease status post coronary artery bypass graft ´2, and an abdominal aortic aneurysm (AAA) status post-EVAR in Venezuela, date unknown. The patient presented with weakness, dizziness, vomiting, and abdominal tenderness. Computed tomography angiography of the abdomen and pelvis (CTA-AP) revealed an AAA measuring up to 9.1 ´ 8.7 cm with a type IIIb endoleak relating to separation of the left common iliac limb from the aortic component and a type Ib leak of the left common iliac limb from the aneurysmal extension. The patient was treated percutaneously with interposition of a stent between the aortic and left common iliac components and a left iliac limb extension. The patient was discharged without complications, and a follow-up CTA-AP was ordered but not completed because of noncompliance. The patient presented to the emergency department almost 2 years later with severe nausea, vomiting, abdominal pain, and fatigue. A CTA-AP revealed a ruptured AAA with active extravasation from a type IIIb endoleak with separation of the right common iliac limb from the abdominal component and a type Ib leak involving both common iliac arteries from the aneurysmal extension. The patient was treated emergently with embolization of the right internal iliac artery and extension of bilateral iliac stents. The patient had an uneventful discharge. The patient presented 3 months later with similar symptomatology. A CTA-AP suspected and angiography confirmed a type Ia leak, which was treated by relining the existing stent graft with proximal extension and renal artery snorkeling. The patient was discharged without complication, and follow-up CTAs 1 and 4 months later demonstrated a small gutter-related type Ia endoleak with a stable AAA.

Results: The result was successful endovascular repair of multiple endoleaks on separate occasions, including AAA rupture management.

Conclusions: Understanding the diagnosis and management of all types of endoleaks is of the utmost importance for all interventional radiologists managing patients with AAA.