Leopardi Marco, Salerno Alessia, Scarpelli Pietro, Ventura Marco
Department of Vascular Surgery Unit, San Salvatore Hospital - University of L'Aquila, Via L. Natali, 67100 L'Aquila, Italy.
CVIR Endovasc. 2018;1(1):9. doi: 10.1186/s42155-018-0020-6. Epub 2018 Nov 6.
The aim of this paper is to describe the case of a patient with a type III endoleak which was misdiagnosed and treated without success as a type I-II endoleak. An incorrect endoleak diagnosis lead to aortic rupture, which could be avoided with a correct diagnosis. Type III B endoleaks presents some diagnostic difficulties, in the case we describe, they were increased by late presentation and poor follow up.
We revised this 89 years old patient history, he underwent EVAR 11 years before, a control scan six month after surgery, showed a type I-II endoleak which was still present after first intervention. He was treated with proximal cuff positioning and embolization coils. Eight years after first intervention, a Computed Tomography Angiography (CTA) showed persisting type I-II endoleak so same problem was suspected and patient was treated with another proximal cuff and right iliac extension. A Magnetic Resonance Imaging (MRI) control, six months later, showed an increase of the aneurysm sac size of 12 mm. Two years later patient presented at emergency room at our hospital with malaise, sweating and abdominal pain. Computed Tomography (CT-scan) showed increased abdominal aortic diameter (140 × 130 mm) with rupture and hemoperitoneum. He was treated in urgent fashion with endograft removal and aortic-iliac Dacron graft reconstruction. During surgery three large tears on endograft fabric and a stent suture rupture were observed. After surgery patient was admitted in intensive care unit and died on second postoperative day due to multiorgan failure.
Type III endoleak is an uncommon complication: a correct and prompt diagnosis is mandatory for appropriate treatment After EVAR, and especially in those cases of known endoleak, a correct follow-up is mandatory and in case of diagnostic doubts correct imaging should be performed. Media contrast allergies should not be neglected and should not represent a CTA limitation.
本文旨在描述一例III型内漏患者的病例，该患者被误诊为I-II型内漏并治疗失败。内漏诊断错误导致主动脉破裂，而正确诊断可避免这种情况。III B型内漏存在一些诊断困难，在我们描述的病例中，由于就诊延迟和随访不佳，这些困难进一步增加。
我们回顾了这位89岁患者的病史，他11年前接受了腔内血管修复术（EVAR），术后6个月的对照扫描显示存在I-II型内漏，首次干预后仍持续存在。他接受了近端袖带定位和栓塞线圈治疗。首次干预8年后，计算机断层血管造影（CTA）显示I-II型内漏持续存在，因此怀疑存在同样的问题，患者接受了另一个近端袖带和右髂动脉延伸治疗。6个月后的磁共振成像（MRI）对照显示动脉瘤囊大小增加了12毫米。两年后，患者因不适、出汗和腹痛到我院急诊室就诊。计算机断层扫描（CT扫描）显示腹主动脉直径增大（140×130毫米），伴有破裂和腹腔积血。他接受了紧急的人工血管移除和主动脉-髂动脉涤纶移植重建治疗。手术中观察到人工血管织物上有三处大的撕裂和一处支架缝线破裂。术后患者被收入重症监护病房，术后第二天因多器官功能衰竭死亡。
III型内漏是一种罕见的并发症：正确及时的诊断对于腔内血管修复术后的适当治疗至关重要，尤其是在已知存在内漏的情况下，必须进行正确的随访，如有诊断疑问，应进行正确的影像学检查。造影剂过敏不应被忽视，也不应成为CTA的限制因素。
