Endovascular treatment for delayed type Ib endoleak with hostile arterial anatomy after endovascular abdominal aortic aneurysm repair

To the Editor: A 71-year-old male patient was referred for incidentally delayed type Ib endoleak on computed tomographic angiography (CTA). He had been performed endovascular abdominal aortic aneurysm repair (EVAR) with the Zenith (Cook Inc, Bloomington, IN, USA) stent-grafts for right common iliac artery (CIA) aneurysm with a diameter of 4.4 cm at 17 months ago. The vital sign was stable, and there was no related symptom. On CTA at 8 months after EVAR, there was no endoleak [Figure 1A]. On this visit, CTA showed that there was a newly developed type Ib endoleak at the left iliac limb [Figure 1B]. So, we tried reintervention via left femoral artery puncture, but it failed because of severe calcific stenosis and tortuosity of the external iliac artery (EIA). Therefore, we performed a left axillary artery puncture. A guidewire was passed into the main body and left limb and was captured by snaring through the left femoral artery. We tried to insert a stent-graft into the distal end of preexisting stent-graft, but could not do it. An angiography showed that the guidewire was passed through a tiny space between the stent and graft, and then came out toward the iliac artery lumen [Figure 1C]. Therefore, another Zenith (Cook Inc, Bloomington, IN, USA) stent-graft with 12 mm in diameter was inserted into EIA to make EIA to be less tortuous. Fortunately, the guidewire was passed through pre-existing stent-graft into the proximal aorta. Finally, a stent-graft with 12 mm in diameter was additionally inserted to manage type Ib endoleak. At the 7th day postoperatively, CTA showed that there was no endoleak [Figure 1D]. The patient was uneventfully discharged.Figure 1: CTA and diagrammatic findings related with EVAR and type Ib endoleak. (A) CTA at post-EVAR 8 months. An arrow indicates no endoleak and good configurated stent-graft in Left. CIA. (B) CTA at post-EVAR 17 months. An arrow indicates type Ib endoleak and angulated stent-graft in Left. CIA. (C) Diagrammatic finding. An arrow indicates the penetrated site by a guidewire between stent and graft. (D) CTA after placement of stent-graft for type Ib endoleak. An arrow indicates no endoleak and recovered stent-graft in Left. CIA. CIA: Common iliac artery; CTA: Computed tomographic angiography; EVAR: Endovascular abdominal aortic aneurysm repair.Recently, EVAR has been emerged as the first treatment of abdominal aortic aneurysm.[1] However, EVAR had a higher risk of reintervention compared to open surgery.[1,2] Type Ib endoleak is mainly due to inadequate anatomy, including large diameter CIA, heavy calcification, or severe aortoiliac tortuous axis.[1,3,4] As a result of type I endoleak, the diameter of aneurysm sac increases, and aneurysm rupture may eventually occur.[5] This is why continuous follow-up after EVAR is essential.[4] When there is severe aortoiliac tortuosity, it may be effective to do a double approach representing both femoral and axillary approaches, or correct the tortuosity by stenting. And then, we can attempt a stent-graft insertion for endoleak.[3,4] In this case, when we attempted a double approach, we thought that the guidewire was traveling within the intended pathway because it was smoothly passed through pre-existing stent-graft, but it was not. We think that the case of penetrating the stent-graft has been extremely unusual and unpredictable. So, performing intermittent angiography during procedures may be the way to prevent greater complications. In reinterventions for type Ib endoleak, it is important to determine whether anatomy has been hostile or not.[3,4] In conclusion, we suggest that it can be helpful to do intermittent angiography during procedures to minimize misread or unpredictable complications. Also, although delayed type Ib endoleak is rare, we think that we need to do a persistent follow-up after EVAR with reminding probability of reinterventions. Conflicts of interest None.