Type IIIB Endoleak Associated to an Iliac Branch Device Bridging Stent.

Abstract

Introduction: Frequently during aortoiliac endovascular exclusion (EVAR), distal fixation at the external iliac artery is needed. Iliac branch devices allow preservation of antegrade flow to the hypogastric artery. These are more complex procedures compared to standard aorto-iliac aneurysm repairs since involve additional arteries, materials, manoeuvers and longer procedural time. In most cases, the procedure is safe and mid-term complications are rare. We report a rare case of an endoleak associated with an iliac branched device during EVAR. Methods: A 75-year-old man with a history of hypertension, dyslipidemia, and former smoker, was intervened by an endovascular exclusion of aorto-iliac aneurysms twenty months earlier. The abdominal aortic aneurysm size was 72 mm and right iliac aneurysm size was 30 mm. A suprarenal aortic stent graft (Zenith LP) and a right iliac branched device (ZBIS) were implanted. A balloon-expandable covered stent of 8x37 mm was used as a bridging stent. During the follow-up, computed tomography angiography (CTA) at 22 months showed a growth of the aneurysmal sac. Catheter angiography was performed, which demonstrated a type III endoleak secondary to stent rupture. Through an open axillary access, endovascular treatment was performed, implanting an overlapping 8x58 mm balloon expandable stent and 8x40 mm self-expanding stent.The completion angiography showed a technical success with a permeability of the endoprosthetic branch and absence of endoleaks. Results: During follow-up, a three-month ultrasound scan and a plain x-ray showed internal iliac branch patency, no stent fracture, and absence of endoleaks. Conclusion: Material related endoleaks associated to the exclusion of an abdominal aortic aneurysm are rare and in branched hypogastric devices, no case has been described. The occurrence of these late complications reinforces the need for post-operatory surveillance of these patients as well as the need to constantly improve the new materials being employed. In most cases, endovascular techniques allow their treatment through a minimally invasive approach with low morbidity.