Inexplicable late type Ia endoleak associated with the low-profile Ovation endograft in a patient with favorable neck anatomy: treatment with transcaval coil embolization

PURPOSE

To report an unusual late type Ia endoleak after endovascular aneurysm repair with a low-profile sealing ring endograft and its treatment with transcaval sac embolization.

CASE REPORT

An 82-year-old man was treated for a 47-mm abdominal aortic aneurysm associated with a 35-mm left common iliac artery aneurysm using an Ovation Abdominal Stent Graft System. Correct endograft placement was documented at 3-month follow-up. Seven months after the repair, the patient was admitted to the emergency department with acute left inguinal pain. Computed tomography showed aneurysm sac enlargement (57 mm) and a contained rupture of the left common iliac artery due to a late type Ia endoleak. The endoleak was embolized with coils and thrombin via a transcaval approach. Sac shrinkage without signs of endoleak was observed at 12-month follow-up.

CONCLUSION

In this case, late endograft failure with sealing ring collapse created an inflow channel into the aneurysm sac, with massive type Ia endoleak.

Chronic contained abdominal aortic aneurysm rupture after suprarenal fixation fatigue fracture

Chronic contained rupture (CCR) of an abdominal aortic aneurysm is a rare condition, and differential diagnosis might be difficult. We present a clinical case of a hemodynamically stable octogenarian who presented with intermittent pain in the left lower abdomen. The patient had a history of diverticulitis, and 6 years ago, he had undergone endovascular abdominal aortic aneurysm repair (EVAR) with a Talent bifurcated prosthesis. Additionally, 20 days before his admission to our hospital, he had undergone a secondary iliac limb extension for treatment of post-EVAR rupture. On admission, abdominal plain radiography identified suprarenal fixation fracture as a possible reason for CCR, but computed tomographic angiography failed to confirm any endoleak or "active" bleeding and rupture. The patient received medication treatment for possible diverticulitis and was kept under close monitoring for suspected failure of recently performed secondary endovascular procedure and CCR. A day later, the abdominal pain symptoms worsened, and a new computed tomographic angiography confirmed the suspected CCR. The patient was treated successfully by "open" repair using a Y prosthesis. To our knowledge, this is the first reported case of post-EVAR CCR due to suprarenal fixation fatigue fracture. Lifelong post-EVAR follow-up with high level of both clinical and imaging diagnostic accuracy is essential for the early recognition and proper treatment of EVAR pitfalls.