Atypical Presentation of a Type 2 Endoleak following Emergency Open Repair of a Ruptured Abdominal Aortic Aneurysm

Abstract

BackgroundAn endoleak is a common complication following EVAR. Specifically, a Type 2 endoleak occurs because of retrograde flow from lumbar vessels outside the endograft within the aneurysm sac. Even though it is common following EVAR, it has not been identified as a complication following open ruptured abdominal aortic aneurysm (AAA) repair.ReportA 73-year-old male underwent open repair of a ruptured AAA. Five months later, computed tomography revealed filling from a lumbar vessel mimicking a Type 2 “endoleak.” The initial ultrasound showed a single pair of lumbar vessels with aneurysm sac expansion 8 weeks later. The “endoleak” and expanding sac were treated, and the 2-year surveillance demonstrated sac shrinkage.DiscussionBecause endoleak is a complication after EVAR, this case provides a unique presentation of Type 2 “endoleak” physiology following open repair of a ruptured AAA. It is believed that it is necessary to expand the list of possible complications after open ruptured AAA repair to include “endoleaks.”

Endovascular Solution to Endoleak Phenomenon After Open Repair of Abdominal Aortic Aneurysm

“…15 Few case reports were found in the literature that used endovascular techniques to repair a type II endoleak after OR. 6,9,10 In our case, despite initial intraoperative validation of cessation of flow within the aortic remnant, a late type II "endoleak" was identified on 6-month follow-up. This is a rare but known complication of the exclusion and ligation technique, noted to occur up to 4% on follow-up.…”

“…The main sources for leak are the IMA and lumbar arteries, just as with EVAR. [9][10][11]14 The authors describe performing redo open operations to identify and ligate the bleeding vessels. Endovascular options also exist, including translumbar coiling, IMA coiling via the superior mesenteric artery, Onyx, and other polymer injections.…”

“…Endovascular options also exist, including translumbar coiling, IMA coiling via the superior mesenteric artery, Onyx, and other polymer injections. 6,9,10 Previous case reports describe endovascular approaches via translumbar, IMA by means of the left colic artery, and brachial access through a coexisting type IA endoleak (Table 1). 6,9,10 Our case demonstrates another unique endovascular method for repair of type II endoleak after OR through a thrombosed access site.…”

“…15 Few case reports were found in the literature that used endovascular techniques to repair a type II endoleak after OR. 6,9,10…”

“…However, in rare instances, there have been reports of a similar "endoleak" phenomenon after OR. 4,5 Type I, II, and III endoleaks following OR have been demonstrated secondary to disruption of anastomotic sites, [6][7][8] patent lumbars, [9][10][11] and midgraft leaks. 5,12 We present a patient with persistent filling of the remnant native aortic and bilateral iliac aneurysm sac from the lumbar and circumflex arteries, creating essentially a type II endoleak situation, and describe our unique solution for this issue.…”