67 yo 10 years s/p abdominal aortic endograft for abdominal aortic aneurysm now with delayed sac enlargement. Patient is asymptomatic. Initial CTA showed vague enhancement of the sac on delayed images and was interpreted as suspicious for a type II endoleak. Diagnostic angiography was requested along with embolization of a type II leak.
A cuff was placed but the leak persisted angiographically. The surgeon elected to follow it the next day hoping for delayed seal.
Interestingly, the type III endoleak was missed on the initial CTA which was read as suspicious for a type II endoleak based on diffuse accumulation of contrast within the aneurysm sac on delayed phase imaging. Type II endoleaks are fairly ubiquitous and often do not cause sac enlargement. These can be watched without intervention. When sac enlargement does occur, embolization of type II endoleaks is generally encouraged when technically feasible. Type III endoleaks should be treated regardless of aneurysm enlargement. Type III endoleaks are far less common than type II endoleaks, which may be why this one was originally missed. They may become more prevalent as in the near future as more and more patients are living longer with older endografts.
For this patient, a cuff failed to resolve the endoleak. Conversion to a unibody graft and fem-fem bypass is planned.
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Case CreditsImages and content graciously provided by:
Jason E. Himmel, MD