CONTAINED GIANT ABDOMINAL AORTIC ANEURYSM RUPTURE SECONDARY TO TYPE I AND III ENDOLEAKS REQUIRING OPEN REPAIR WITH ENDOGRAFT EXPLANTATION

Objectives: Minimally invasive treatment for increasingly complex abdominal aortic aneurysms (AAA) can be accomplished through endovascular aneurysm repair (EVAR). A common complication of EVAR, occurring in approximately 25% of patients, is continued blood flow in the aneurysm sac external to the stent graft, known as an endoleak. Type I endoleaks occur at either end of the stent graft, resulting from an inadequate seal at the attachment site between the graft and artery with a reported incidence of up to 20%. Type III endoleaks occur in approximately 2 % of EVARs when persistent blood flow is attributed to defects between the components in modular grafts (IIIa) or from a defect in the stent graft itself, such as a fabric tear or stent fracture (IIIb). Urgent re-intervention is indicated for type I and type III endoleaks due to systemic pressurization of the aneurysm sac resulting in a high risk of aneurysm rupture.

A 68 year-old man presented with an infrarenal AAA and underwent EVAR. He developed a late Type I endoleak requiring a second intervention with placement of an additional stent graft cuff at the proximal attachment site to seal the endoleak. Several months later, he presented with continued aneurysmal sac expansion secondary to a recurrent Type I endoleak and a new Type IIIb endoleak. The AAA had increased in size to 18 cm in diameter, with a contained rupture. He underwent emergent endograft explantation and open repair with a bifurcated Dacron graft via a transabdominal approach with supra-celiac aortic clamping. The duodenum was adherent to the proximal aneurysm neck and was injured in the dissection. His post-operative course was uncomplicated.

EVAR has become the standard of care for the treatment of most AAA. Post-operative follow-up with serial imaging is required to identify endoleaks. Type I and III endoleaks must be aggressively treated in order to prevent aneurysm sac enlargement and rupture.

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