Surgery for a Late Type IIIb Endoleak From a Fabric Tear of an Excluder Stent Graft.

An 85-year-old male patient, who had undergone endovascular abdominal aortic aneurysm repair (EVAR) using the Gore Excluder stent graft 10 years ago, was referred for intermittent abdominal pain. He also received coil embolization of the lumbar arteries for a persistent type II endoleak, resulting in continued aneurysmal dilation at 4, 6, and 8 years after the EVAR. The maximum size of the aneurysm sac was dilated from the initial size of 49 mm × 55 mm to 78 mm × 90 mm, and the contrast medium was observed around the proximal portion of the stent graft, suggesting the presence of a type Ia or II endoleak. Because the definite cause of the dilation was unclear and adequate proximal landing zone was not available to deploy an aortic cuff, emergent laparotomy was indicated to treat this symptomatic aneurysm dilation. A type IIIb endoleak due to fabric disruption of the main body was diagnosed, and the bleeding was controlled using a fibrin sealant patch. To reinforce the hemostasis site from the inside of the stent graft, a 28 mm × 3-cm Excluder aortic cuff was deployed inside the main trunk next day. At 1-year follow-up, his condition was stable without evidence of reexpansion of the aneurysmal sac.