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Case Report| Volume 58, P15-18, 2023

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Giant Sac Growth: A Hybrid Approach to Treat a Misdiagnosed Late Type IIIb Endoleak

Open AccessPublished:February 26, 2023DOI:https://doi.org/10.1016/j.ejvsvf.2023.02.004

      Highlights

      • Type IIIb endoleaks result from fabric tears and are rare with newer devices.
      • These endoleaks are often misdiagnosed and can mimic other types.
      • Late type IIIb endoleaks occur and cause aneurysm growth due to high pressure leak.
      • Endovascular treatment is first option but hybrid approach can help identify leak.

      Introduction

      Endoleaks are a common complication following endovascular aneurysm repair, yet type IIIb are rare, especially with newer devices, and associated with high morbidity due to repressurisation of the sac. As endografts are used in patients with longer life expectancy, late type IIIb endoleaks are to be expected. This is a report of a giant common iliac aneurysm resulting from a misdiagnosed type IIIb endoleak.

      Report

      An 85 year old man with history of right common iliac artery aneurysm, treated in 2003 with an EXCLUDER AAA Endoprosthesis (WL Gore, Flagstaff, AZ, USA) with iliac limb extension into the external iliac artery, presented at the emergency department with abdominal pain, hypotension, and syncope. He had a known endoleak, unsuccessfully treated by relining the right iliac stent graft overlap zones for a suspected type IIIa endoleak (2009), coil embolisation, and computed tomography (CT) guided thrombin injection of the aneurysmatic sac for a type II (2010), none of which managed to treat the cause with continuous aneurysm growth. The patient refused further treatments, but agreed to maintain surveillance. At admission, CT angiography showed common iliac aneurysm (185 × 134 mm) sac rupture without a visible endoleak. Resuscitative endovascular balloon occlusion of the aorta (REBOA) technique was performed to obtain haemodynamic control, then the aneurysm was approached through a midline incision. A type IIIb endoleak was identified due to a fabric tear on the right iliac limb extension. Suture was attempted without success, then relining of the lesion with an Endurant II Limb (Medtronic, Minneapolis, MN, USA) was performed, which managed to repair the endoleak.

      Discussion

      Type IIIb endoleaks are uncommon and underdiagnosed due to fabric defects being too small or leaking intermittently. They can mimic other types of endoleaks and may cause aneurysm growth and rupture. One should consider this type of endoleak if previous treatments for other types were unsuccessful.

      Keywords

      Introduction

      Endovascular aneurysm repair (EVAR) is a common modality for the treatment of aortoiliac aneurysms. Endoleaks make up for 2 – 45% of all complications following EVAR.
      • Varsanik M.A.
      • Pocivavsek L.
      • Babrowski T.
      • Milner R.
      Diagnostic colour duplex ultrasound for type IIIb endoleak.
      • Kwon J.
      • Dimuzio P.
      • Salvatore D.
      • Abai B.
      Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair.
      • Lowe C.
      • Hansrani V.
      • Madan M.
      • Antoniou G.A.
      Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review.
      These are typically divided into five categories depending on their location and source, with type III endoleaks being caused either by modular disconnection (type IIIa) or stent graft tear and fabric defect (type IIIb).
      • Lowe C.
      • Hansrani V.
      • Madan M.
      • Antoniou G.A.
      Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review.
      ,
      • Shao J.
      • Zhang X.
      • Chen Y.
      • Zheng Y.
      • Liu B.
      Endovascular repair of late type IIIb endoleak after endovascular aneurysm repair: a case report.
      As other types of endoleak, type III can be divided into early or late. While early type IIIb endoleaks are rare, especially in newer devices, often resulting from manufacturing errors or fabric tear during manipulation of the endograft,
      • Stoecker J.B.
      • Glaser J.D.
      Review of type III endoleaks.
      late type IIIb endoleaks, take months to years to develop, with an average of 5.6 years after implantation. This results from chronic deterioration of the fabric and stent sutures as well as from continuous transmission of pulsatile pressure, causing tears and holes at the endograft (type IIIb).
      • Stoecker J.B.
      • Glaser J.D.
      Review of type III endoleaks.
      ,
      • Nishibe T.
      • Iwahashi T.
      • Kamiya K.
      • Kano M.
      • Maruno K.
      • Koizumi J.
      • et al.
      Type IIIb endoleak after endovascular aneurysm repair using the Zenith Stent graft.
      As stent grafts are progressively being used in younger patients with longer life expectancy, long term complications following these procedures are to be expected, namely regarding the durability of the materials used.
      • Kwon J.
      • Dimuzio P.
      • Salvatore D.
      • Abai B.
      Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair.
      This is a report of a case of type IIIb endoleak as a late complication following EVAR.

      Report

      An 85 year old man with hypertension, high cholesterol, and pulmonary fibrosis, presented at the emergency department for acute abdominal pain that had started the same day, associated with loss of consciousness that lasted less than a minute. He had history of right common iliac artery aneurysm, which underwent endovascular repair in 2003 with an EXCLUDER AAA Endoprosthesis (WL Gore, Flagstaff, AZ, USA) with an iliac extension into the right external iliac artery, without embolisation of the internal iliac artery.
      Six years after the procedure (2009), aneurysmatic growth was evidenced by abdominal CT angiography, suggestive of a type IIIa endoleak through the connection between the endograft and the right iliac limb, which was treated by relining the leak using a balloon expandable covered stent (16 × 61 mm). The patient maintained signs of sac growth, on routine follow up through duplex ultrasound and CT angiography, which was later attributed to a type II endoleak through lumbar and pelvic collaterals. Coil embolisation of the right internal iliac artery and collaterals and CT guided thrombin injection of the aneurysmatic sac was attempted (2010), but nothing had managed to successfully treat the aneurysm. In 2011, the patient refused any further treatments either by open surgery or endovascular procedures; he was kept on annual follow up at the outpatient clinic, showing progressive growth of the aneurysm (Figure 1A and B).
      Figure thumbnail gr1
      Figure 1Follow up computed tomography (CT) scans showing progressive aneurysm growth of the right common iliac artery: 2017 – 114 × 120 mm (A); 2020 – 133 × 155 mm (B). And CT scan performed at the emergency department, revealing aneurysm rupture: 2022 – 134 × 187 (C).
      On arrival at the emergency department, the patient was hypotensive with a blood pressure of 64/31 mmHg and tachycardic (109 bpm), pale with cold extremities and mentioned localised tenderness at the right lumbar and iliac regions during abdominal palpation. Pathology demonstrated haemoglobin of 9.5 g/dL.
      An emergency abdominal CT angiography was performed, revealing haematic content in the abdominal cavity surrounding the previously known aneurysm (187 × 134 mm) and infiltrating the perirenal fat bilaterally, yet without a visible endoleak (Figure 1C).
      Upon agreeing to life saving surgery, the patient was immediately taken to the operating room. A REBOA technique to achieve haemodynamic stability was performed through a retrograde left femoral artery access, using a Reliant stent graft balloon catheter (Medtronic, Minneapolis, MN, USA), advanced through a 12F sheath that was inflated at the descending thoracic aorta. A midline incision was performed and the aneurysm sac was opened, followed by thrombus removal. No signs of type II endoleak were found, yet a fissure like tear in the fabric of the endograft at the right iliac limb was identified as the cause of the chronic endoleak (type IIIb) (Figure 2).
      Figure thumbnail gr2
      Figure 2Giant common iliac aneurysm was identified after midline laparotomy (A). This was followed by emptying and removing thrombus from the aneurysmatic sac (B). A small tear at the right iliac limb extension (circle) of the endograft was identified. The zoomed image at the upper right corner marks the location of the tear with an arrow (C).
      Direct suture of the lesion was attempted, as well as pledget re-inforcement of the tear, without managing to control the bleeding after intermittent balloon deflation, therefore, an endovascular approach was taken to treat the stent graft tear. A curved haemostatic forceps was used as a reference to mark the level of the tear, then a retrograde right femoral access was obtained and an Endurant II Limb (16 × 16 × 82 mm) (Medtronic, Minneapolis, MN, USA) stent graft was used for relining the lesion, successfully managing to treat the type IIIb endoleak (Figure 3).
      Figure thumbnail gr3
      Figure 3Curved haemostatic forceps was used to reference the tear, then a stent graft was released to reline the lesion (A and B).
      The patient survived the procedure and was discharged at 35 days post-op, after a 20 day stay at the intensive care unit, almost completely independent although still under physical therapy. He was admitted one week later at his local hospital with acute respiratory failure and was later diagnosed with hospital acquired pneumonia. The patient passed 44 days after the initial surgery.

      Discussion

      Endovascular aneurysm repair is associated with lower morbidity and mortality in the short term when compared with open surgery. Long term complications are not uncommon, however, and these are associated with a higher rate of secondary interventions when compared with open repair.
      • Stoecker J.B.
      • Glaser J.D.
      Review of type III endoleaks.
      The incidence of type III endoleaks ranges from 1.4% to 4.5% in different studies, with first and second generation devices reaching 8 – 12%, and these are associated with aneurysm growth and rupture.
      • Varsanik M.A.
      • Pocivavsek L.
      • Babrowski T.
      • Milner R.
      Diagnostic colour duplex ultrasound for type IIIb endoleak.
      ,
      • Shao J.
      • Zhang X.
      • Chen Y.
      • Zheng Y.
      • Liu B.
      Endovascular repair of late type IIIb endoleak after endovascular aneurysm repair: a case report.
      ,
      • Stoecker J.B.
      • Glaser J.D.
      Review of type III endoleaks.
      In a systematic review by Lowe et al., 70% of patients with type III endoleak had aneurysm expansion and 26% presented with a ruptured aneurysm.
      • Lowe C.
      • Hansrani V.
      • Madan M.
      • Antoniou G.A.
      Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review.
      This can be justified by the fact that type IIIb endoleaks represent high pressure leaks, contributing to continuous aneurysm growth and rupture.
      • Varsanik M.A.
      • Pocivavsek L.
      • Babrowski T.
      • Milner R.
      Diagnostic colour duplex ultrasound for type IIIb endoleak.
      Data regarding long term durability of stent grafts is still lacking and although newer generations of stent grafts seem more reliable than older ones, fabric tear may not be as rare as previously considered, which may be one of the causes of increased EVAR re-interventions over time.
      • Kwon J.
      • Dimuzio P.
      • Salvatore D.
      • Abai B.
      Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair.
      ,
      • Fujimura N.
      • Ichihashi S.
      • Matsubara K.
      • Shibutani S.
      • Harada H.
      • Obara H.
      • et al.
      Type IIIb endoleak is not extremely rare and may be underdiagnosed after endovascular aneurysm repair.
      In a series from Maleux et al., in first and second generation endografts, fabric defects accounted for 40% of type III endoleaks, against 16.7% in third generation endografts, as was the case of the stent graft used in this patient. Despite these findings, the difference was not statistically significant.
      • 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.
      Fujimura et al. suggest that possible causes of type IIIb endoleak include placement of bare metal stents, neck tortuosity, stent fracture, spontaneous fabric tear, and excessive balloon dilation.
      • Fujimura N.
      • Ichihashi S.
      • Matsubara K.
      • Shibutani S.
      • Harada H.
      • Obara H.
      • et al.
      Type IIIb endoleak is not extremely rare and may be underdiagnosed after endovascular aneurysm repair.
      The cause of the type IIIb endoleak is not clear in the presented case, yet one can argue that the late onset nature of this case resulted from a chronic deterioration of the fabric due to continuous transmission of pulsatile pressure rather than mishandling of the graft or overdilation as these would relate to an earlier presentation after the procedure.
      • Stoecker J.B.
      • Glaser J.D.
      Review of type III endoleaks.
      Cao et al. report degradation phenomena on older homemade endografts, yet the authors state that even newer devices should take into account fabric fatigue and corrosion.
      • Cao S.H.
      • Canonge J.
      • Gaudric J.
      • Dion D.
      • Kuntz S.
      • Jayet J.
      • et al.
      Degradation phenomena on “homemade” explanted aortic textile endografts.
      Although type IIIb endoleaks are considered to be rare, these are probably underdiagnosed as most studies do not differentiate between types IIIa and IIIb.
      • Nishibe T.
      • Iwahashi T.
      • Kamiya K.
      • Kano M.
      • Maruno K.
      • Koizumi J.
      • et al.
      Type IIIb endoleak after endovascular aneurysm repair using the Zenith Stent graft.
      In addition, their diagnosis is challenging, often requiring multimodal imaging methods, due to the fabric tears being either too small or leaking only intermittently, with only 20% of type IIIb endoleaks being diagnosed on CTA,
      • Varsanik M.A.
      • Pocivavsek L.
      • Babrowski T.
      • Milner R.
      Diagnostic colour duplex ultrasound for type IIIb endoleak.
      with contrast enhanced ultrasound and magnetic resonance angiography posing as promising alternatives due to their high sensitivity to detect blood flow changes.
      • Varsanik M.A.
      • Pocivavsek L.
      • Babrowski T.
      • Milner R.
      Diagnostic colour duplex ultrasound for type IIIb endoleak.
      ,
      • Kwon J.
      • Dimuzio P.
      • Salvatore D.
      • Abai B.
      Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair.
      Angiography may also prove useful in revealing small fabric tears, through selective contrast injection at different segments within the endograft, achieved with balloon occlusion.
      • Kwon J.
      • Dimuzio P.
      • Salvatore D.
      • Abai B.
      Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair.
      One should also remember that duplex ultrasound is a valuable tool in the follow up of patients submitted to EVAR. Despite being the least sensitive method of endoleak detection, this may be due to operator dependent limitations as well as patient body habitus, it is cheap, easy to perform, non-invasive, and does not require exposure to contrast or radiation. Intra-operatively, ultrasound can also be a valuable tool to identify type III endoleaks that cannot be accurately localised by angiography.
      • Morgan-Bates K.
      • Dey R.
      • Chaudhuri A.
      Ultrasound assisted on-table management of type III endoleak at endovascular repair of isolated giant common iliac aneurysm.
      As in the present case, type IIIb endoleaks can also be misdiagnosed and mimic other types of endoleak, leading to continuous aneurysm growth despite multiple treatment attempts, which in this particular case, ultimately led to the patient refusing any further treatment despite being warned of the risks concerning aneurysm rupture. Hence one should suspect of this particular type of endoleak if previous attempts to treat other causes have been unsuccessful in achieving aneurysm exclusion.
      • Lowe C.
      • Hansrani V.
      • Madan M.
      • Antoniou G.A.
      Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review.
      Lastly, most studies seem to suggest an endovascular approach as the first line option to treat type III endoleaks,
      • Lowe C.
      • Hansrani V.
      • Madan M.
      • Antoniou G.A.
      Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review.
      ,
      • Shao J.
      • Zhang X.
      • Chen Y.
      • Zheng Y.
      • Liu B.
      Endovascular repair of late type IIIb endoleak after endovascular aneurysm repair: a case report.
      ,
      • 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.
      yet despite the present patient ultimately being treated endovascularly, the initial approach was through traditional open surgery as the cause of the endoleak could not be confirmed, thus showing that in cases where the source of the endoleak is hard to diagnose a hybrid approach can be a viable option for treatment.

      Conclusion

      Type III endoleaks are associated with a high risk of aneurysm expansion and rupture, with type IIIb, in particular, posing as a challenging diagnosis, often requiring multimodal imaging methods and mimicking other endoleaks. As EVAR is used in an ever younger population, with a longer life expectancy, complications related to endograft durability will likely become more frequent. Clinicians should be aware of these complications when aneurysm exclusion is unsuccessful after attempted treatment for other types of endoleak.

      Conflict of interest

      None.

      Funding

      None.

      References

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        Diagnostic colour duplex ultrasound for type IIIb endoleak.
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        Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair.
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        Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review.
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        Endovascular repair of late type IIIb endoleak after endovascular aneurysm repair: a case report.
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        Review of type III endoleaks.
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        Type IIIb endoleak after endovascular aneurysm repair using the Zenith Stent graft.
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        • Ichihashi S.
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        Degradation phenomena on “homemade” explanted aortic textile endografts.
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