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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 54-57

Case report of type IIIa endoleak after endovascular aortic repair

Department of Diagnostic and Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China

Date of Submission04-Dec-2021
Date of Decision22-Mar-2022
Date of Acceptance24-Mar-2022
Date of Web Publication24-Jun-2022

Correspondence Address:
Prof. Xi Guo
Department of Diagnostic and Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2589-9686.348223

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An 81-year-old male presented to our emergency department for abdominal pain and distension. The patient had previously undergone endovascular aortic repair (EVAR) procedure 9 years ago for infrarenal abdominal aortic aneurysm with regular follow-up in postoperative. Three years ago, computed tomography angiography (CT) revealed Type Ib endoleak with right common iliac artery expansion and Type II endoleak from inferior mesenteric artery (IMA). Then, the patient was successfully treated by relining the iliac stent-graft to cover the common iliac expansion and coil embolism to occlude IMA through the Riolan's arch using endovascular technique. Recently, the following up CTA displayed a new Type IIIa endoleak, which the left iliac limb was disconnected with the main body graft. The patient was ultimately successful to treat by implanting stent-grafts using endovascular therapy. This case emphasizes the necessity of follow-up examination for lifelong stent-grafts surveillance. We debated the current late-related complication of EVAR and stent-graft migration treatment choices.

Keywords: Abdominal aortic aneurysm, endovascular aortic repair, type IIIa endoleak

How to cite this article:
Han X, Guo X, Liu G, Li T. Case report of type IIIa endoleak after endovascular aortic repair. Vasc Invest Ther 2022;5:54-7

How to cite this URL:
Han X, Guo X, Liu G, Li T. Case report of type IIIa endoleak after endovascular aortic repair. Vasc Invest Ther [serial online] 2022 [cited 2022 Aug 19];5:54-7. Available from: https://www.vitonline.org/text.asp?2022/5/2/54/348223

  Introduction Top

Type III endoleak is a rare late complication. Complications related to endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA), which estimate the incidence of 3%–4.5% range.[1],[2],[3] Its characteristic is fabric disruption of stent-graft (Type IIIb) and modular disconnection (Type IIIa) between the main body and the iliac limb. Type III endoleak shows the predominant role in causing rupture or conversion to open surgery in post-EVAR because of repressurizing. We report a rare case of Type IIIa endoleak developing nearly a decade after the occurrence of Type II and Type Ib endoleaks in post-EVAR.

  Case Report Top

An 81-year-old male with a decade of cardiovascular artery disease, more than 30 years of hypertension, hyperlipidemia, and with nearly 40 years of tobacco use was admitted with half-month abdominal pain and distension. This patient had previously undergone an EVAR for infrarenal AAA at 9 years ago with a bifurcated endovascular aortic Zenith device (Cook, Bloomington, IN). Until 3 years ago, the patient used to do the regular surveillance and was free to any EVAR-related complication or reintervention. Moreover, then he underwent to reline the stent-graft to the common iliac artery to cover Type Ib endoleak because of the right common iliac artery aneurysm formation, as well as to use coil embolism in inferior mesenteric artery to occlude the Type II endoleak through Riolan's arch.

Before 3 years, a computed tomography angiography (CTA) displayed that the right common iliac artery aneurysm formation (Type Ib endoleak) and Riolan's arch access open (Type II endoleak) [Figure 1]. In view of the endovascular technique to successfully treat Type Ib and II endoleak, regular CTA imaging follow-up was to be continued until now. At this admission, the preoperative CTA image showed that the left limb of stent-graft was disconnected with the main body (Type IIIa endoleak), with an interval expansion in the size of the aneurysm sac from 96.96 cm2 to 156.8 cm2 in the past 3 years. The patient was cautioned and took percutaneous relining of the Endurant limbs stent-graft (Medtronic Ltd., Dublin, Ireland) through the through wire snared technique to set up a track from the left femoral artery to the left brachial artery. Although building the through wire tract, right limb stent-graft occurred the disconnection with the main body during the procedure of deploying the left Endurant limbs, probably as the main body is relatively short but angulated. Hence, the right Endurant limb stent-grafts had to be deployed to reconnection the main body from the right lateral groin. Fortunately, this patient underwent the procedure well and the operation was successfully completed, as well did not complain the further abdominal pain. This patient recovered well and was discharged 3 days in postprocedure.
Figure 1: (a) 81-year-old patient presented with a Type III endoleak 9 years later after initial endovascular aortic repair. A postendovascular aortic repair follow-up 6 years showed Type Ib and Type II endoleak (yellow arrow) through the distal part of stent-graft of right common iliac artery aneurysm formation (a1) and inferior mesenteric artery (a2), which was managed by placement of Endurant limb extension to cover the expansion and coil embolism to inferior mesenteric artery through Riolan's arch. (b) Half-year later, right external iliac artery sealing well (b2) and Riolan's arch close, which measured the maximum aneurysm area was 96.96 square centimetres (b1). (c) Three years later, a new disconnection and Type III endoleak (yellow arrow) were identified between main body and left iliac limb (c1), which calculated the maximum aneurysm area was 156.8 cm2 (c2). (d) Perioperative angiography displayed the disconnection position (d1) in the left limb and main body, and in the process of pushing-up the Endurant limb stent-graft, right limb stent disconnection occurred (d2), finally angiography showed the sealing and reconnection of both iliac limb stent-graft (d3), the Type III endoleak completely disappeared (yellow arrow)

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  Discussion Top

Since EVAR became an effective substitute to open surgery for AAA, endoleak, as the middle of Achilles, represented one of the common complications, which was nominated by White et al. that blood leakage into aneurysm sac in post-EVAR.[4] Type III endoleak, as well as Type I endoleak, is considered to be a life-threatening endoleak with an increasing risk of aneurysm sac rupture. There, respectively, reported the 3% and 3.5% incidence of Type III endoleak in the OVER trial[2] and EUROSTAR registry[5] in the early years, but nowadays, third-generation endografts showed a significant reduction in the incidence of Type III endoleak. Maleux et al. reported a 2.1% incidence of Type III endoleak but nearly 10% of patients with Type III endoleak presented with a rupture as the first sign of the endoleak, emphasizing the importance of early repair of Type III endoleak once radiologic definitely diagnosis.[6] Hence, regular surveillance, such as CTA for periodic follow-up, is an efficient method to patients happened endoleaks anyway in post-EVAR.

Based on retrospective analysis to 701 patients, Skibba et al.[7] illustrated that predictors related to Type IIIa endoleak were large diameter AAA, short or angulated aortic neck, AAA tortuosity, same size using between main body and extension, and component insufficient overlapping. Another negative characteristic specially reported by Castelli et al.[8] was aortic tortuosity index, which increase more than 0.03 on the basis of comparison in twice post-EVAR CTA scan more than 18-month interval. At our case, the patient was presented with the similar characteristics, such as more than 30 years of tobacco use, large aneurysm sac, angulated neck, and torturous iliac artery.

Endovascular treatment of Type IIIa endoleak as first-line choice is employed, which provided quickly and free to cross-clamping of the abdominal aorta. The mainly technical difficulty was overcome to negotiate the offset components to plug into the main body, as in this case via the through wire tract. Instead of endovascular repair failure, surgical repair could be carried out, including preserved endograft through re-suturing, partial reanastomosis, or total replacement, but facing with great challenge to remove the proximal endograft with barbs, hooks, or suprarenal stents.[9],[10]

Special to this patient, a new Type IIIa endoleak was identified 3 years later after the treatment of Type II and Type Ib endoleaks in post-EVAR. We are confused that what caused this patient with high frequently recurrent endoleak. The angulated neck and tortuosity iliac artery may be the negative factors to cause the Type III endoleak, but no flow analysis was used to determine the aortic pulsatile flow force and affect the stent-graft movement. Furthermore, analysis based on comparison of angulated and nonangulated fixation would be calculated, meanwhile evaluating the impact degree of tortuosity to the stent-graft of different commercial use. In addition, considering that we are no longer performing EVAR with Zenith device, during this procedure, Endurant iliac limbs were used to seal the disconnection. As this case demonstrated, an EVAR-related complication-free after 6-year interval period and then another 3-year freedom after reintervention, aortic stent grafts surveillance should be emphasized the importance and necessity for the whole life once again.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


Thanks to my wife and family for their support and encouragement.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

United Kingdom EVAR Trial Investigators; Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-71.  Back to cited text no. 1
Lal BK, Zhou W, Li Z, Kyriakides T, Matsumura J, Lederle FA, et al. Predictors and outcomes of endoleaks in the Veterans Affairs Open Versus Endovascular Repair (OVER) Trial of Abdominal Aortic Aneurysms. J Vasc Surg 2015;62:1394-404.  Back to cited text no. 2
Hobo R, Buth J, EUROSTAR Collaborators. Secondary interventions following endovascular abdominal aortic aneurysm repair using current endografts. A EUROSTAR report. J Vasc Surg 2006;43:896-902.  Back to cited text no. 3
White GH, Yu W, May J. Endoleak – A proposed new terminology to describe incomplete aneurysm exclusion by an endoluminal graft. J Endovasc Surg 1996;3:124-5.  Back to cited text no. 4
Harris PL, Vallabhaneni SR, Desgranges P, Becquemin JP, van Marrewijk C, Laheij RJ. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: The EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm repair. J Vasc Surg 2000;32:739-49.  Back to cited text no. 5
Maleux G, Poorteman L, Laenen A, Saint-Lèbes B, Houthoofd S, Fourneau I, et al. Incidence, etiology, and management of type III endoleak after endovascular aortic repair. J Vasc Surg 2017;66:1056-64.  Back to cited text no. 6
Skibba AA, Evans JR, Greenfield DT, Yoon HR, Katras T, Ouriel K, et al. Management of late main-body aortic endograft component uncoupling and type IIIa endoleak encountered with the Endologix Powerlink and AFX platforms. J Vasc Surg 2015;62:868-75.  Back to cited text no. 7
Castelli MA, Pfund G, Auza D, Battú C, Balestrini J, De Luca I, et al. Predictors of type IIIa endoleak after endovascular aortic repair with anatomic fixation endografts. J Vasc Surg 2022;75:1583-1590.e1.  Back to cited text no. 8
Lipsitz EC, Ohki T, Veith FJ, Suggs WD, Wain RA, Rhee SJ, et al. Delayed open conversion following endovascular aortoiliac aneurysm repair: Partial (or complete) endograft preservation as a useful adjunct. J Vasc Surg 2003;38:1191-8.  Back to cited text no. 9
Bellamkonda K, Ochoa Chaar CI. Open repair of type III endoleak with preservation of the endograft for a ruptured abdominal aortic aneurysm after endovascular aneurysm repair. J Vasc Surg Cases Innov Tech 2021;7:117-9.  Back to cited text no. 10


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