Type IIIb endoleak on CTA

Type III Endoleak

Clinical History

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.


Angiography


Image 1.1

These images reveal a surprise type IIIb endoleak arising from the main body of the endograft near an area of graft deformity just above the flow divider on the patient's right.  







Discussion

A cuff was placed but the leak persisted angiographically.  The surgeon elected to follow it the next day hoping for delayed seal.

 


Follow-up CTA from Post-op Day 1

CT image in the arterial phase taken one day after cuff placement reveals a persistent type III leak. This was missed on the previous CTA which was interpreted as probably type II endoleak based on diffuse peripheral aneurysm enhancement on delayed imaging.


Image 2.1

The image in the early arterial phase reveals a persistent Type IIIb endoleak.  









Case Discussion

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.​

 

Social media tags: #AAA #abdominalaorticaneurysm #stentgraft #aorta #endoleak #angiography #aortography #interventionalradiology #vascularsurgery

 


Case Credits

Images and content graciously provided by:

Jason E. Himmel, MD


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