A New Technique Using a Stent and a Plug for the Management of Persistent Type IIIc Endoleak Following Fenestrated Endovascular Aortic Repair (FEVAR)

Fenestrated endovascular repair (FEVAR) has become a safe and effective option for the treatment of complex aortic aneurysms (CAA). Complications can occur, including endoleaks like type IIIc endoleak, characterized by flow between a fenestration and its bridging stent. Although some endoleaks may resolve spontaneously, most require secondary interventions to prevent further expansion of the aneurysmal sac and other complications. We describe a percutaneous “stent-and-plug” rescue maneuver performed in 5 consecutive patients with refractory type IIIc endoleaks after company-manufactured FEVAR grafts. Under moderate sedation and bilateral femoral access, the target-vessel stent was balloon-protected while the free space of the fenestration causing the endoleak was catheterized contralaterally; a 5 × 16 mm iCast™ stent was deployed within the fenestration, and an Amplatzer vascular plug was positioned inside the new stent. Then, the renal-stent balloon was re-inflated to crush the stent-plug complex and achieve a seal in the fenestration. Endoleaks emerged at a mean of 2.47 months (range 1.10-7.1) after the index repair, persisting despite one (n = 3) or 2 (n = 2) prior angioplasty or re-stenting attempts. The stent-and-plug technique achieved technical success in 4 of the 5 cases; the remaining case required one additional procedure to achieve complete sealing. No renal branch occlusion, dialysis-requiring renal injury, or procedure-related mortality occurred. The mean follow-up after rescue was 8.96 months (range 1.4-15.3), with no sac growth observed. Stenting and plugging the fenestration-free space offers a feasible option for treating persistent type IIIc endoleaks when conventional secondary interventions fail; extended surveillance is necessary to confirm long-term durability.