Delayed type Ia endoleak after EVAR for complex aorto-iliac aneurysmal disease with bilateral internal iliac artery aneurysms: successful repair with a proximal aortic cuff – a case report

Introduction and importance: Extensive aorto-iliac aneurysmal disease presents major challenges for endovascular aneurysm repair (EVAR), particularly when both the common and internal iliac arteries are aneurysmal, limiting standard endovascular options. Case presentation: A 78-year-old overweight woman with coronary artery disease presented with a 64-mm infrarenal abdominal aortic aneurysm, a short, severely angulated proximal neck, bilateral common iliac aneurysms, and bilateral internal iliac aneurysms. Standard EVAR and iliac branch reconstruction were unsuitable because of absent distal landing zones and unfavorable anatomy. A staged endovascular approach was performed, with bilateral internal iliac artery coil embolization followed by EVAR using a Cook endograft extended into both external iliac arteries. One-year computed tomography angiography (CTA) showed patent graft limbs without endoleak. At 2 years, CTA detected a delayed type Ia endoleak caused by proximal graft displacement. Secondary EVAR with a proximal aortic cuff successfully restored the proximal seal. Clinical discussion: This case demonstrates that individualized EVAR can successfully treat complex aorto-iliac aneurysms despite unfavorable anatomy. However, hostile neck anatomy increases the risk of delayed proximal seal failure. Conclusion: EVAR may be a feasible option for selected high-risk patients with complex aorto-iliac aneurysms. Lifelong imaging surveillance is essential, and a delayed type Ia endoleak can be effectively treated with a proximal aortic cuff when an adequate proximal landing zone is preserved.