Silva Eduardo, Nunes Celso, Baldaia Leonor, Castro Miguel, Oliveira Vânia Constâncio, Silva Joana, Antunes Luís F
Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal.
EJVES Vasc Forum. 2023 Feb 27;58:15-18. doi: 10.1016/j.ejvsvf.2023.02.004. eCollection 2023.
Endoleaks are a common complication following endovascular aneurysm repair, yet type IIIb are rare, especially with newer devices, and associated with high morbidity due to repressurisation of the sac. As endografts are used in patients with longer life expectancy, late type IIIb endoleaks are to be expected. This is a report of a giant common iliac aneurysm resulting from a misdiagnosed type IIIb endoleak.
An 85 year old man with history of right common iliac artery aneurysm, treated in 2003 with an EXCLUDER AAA Endoprosthesis (WL Gore, Flagstaff, AZ, USA) with iliac limb extension into the external iliac artery, presented at the emergency department with abdominal pain, hypotension, and syncope. He had a known endoleak, unsuccessfully treated by relining the right iliac stent graft overlap zones for a suspected type IIIa endoleak (2009), coil embolisation, and computed tomography (CT) guided thrombin injection of the aneurysmatic sac for a type II (2010), none of which managed to treat the cause with continuous aneurysm growth. The patient refused further treatments, but agreed to maintain surveillance. At admission, CT angiography showed common iliac aneurysm (185 × 134 mm) sac rupture without a visible endoleak. Resuscitative endovascular balloon occlusion of the aorta (REBOA) technique was performed to obtain haemodynamic control, then the aneurysm was approached through a midline incision. A type IIIb endoleak was identified due to a fabric tear on the right iliac limb extension. Suture was attempted without success, then relining of the lesion with an Endurant II Limb (Medtronic, Minneapolis, MN, USA) was performed, which managed to repair the endoleak.
Type IIIb endoleaks are uncommon and underdiagnosed due to fabric defects being too small or leaking intermittently. They can mimic other types of endoleaks and may cause aneurysm growth and rupture. One should consider this type of endoleak if previous treatments for other types were unsuccessful.
内漏是血管内动脉瘤修复术后常见的并发症，但IIIb型内漏罕见，尤其是在使用新型器械时，且由于瘤腔再 pressurisation 会导致高发病率。随着血管内移植物应用于预期寿命较长的患者，晚期IIIb型内漏是可以预期的。本文报告一例因误诊的IIIb型内漏导致的巨大髂总动脉瘤。
一名85岁男性，有右髂总动脉瘤病史，2003年接受EXCLUDER AAA血管内支架移植物（美国亚利桑那州弗拉格斯塔夫的WL Gore公司）治疗，髂支延伸至股外动脉，因腹痛、低血压和晕厥就诊于急诊科。他已知存在内漏，曾因疑似IIIa型内漏对右髂支架移植物重叠区域进行内衬修复（2009年）、弹簧圈栓塞以及对II型内漏进行计算机断层扫描（CT）引导下瘤腔注射凝血酶（2010年），但均未能解决问题，动脉瘤持续增大。患者拒绝进一步治疗，但同意进行监测。入院时，CT血管造影显示髂总动脉瘤（185×134mm）瘤腔破裂，未见明显内漏。采用复苏性血管内主动脉球囊阻断术（REBOA）以控制血流动力学，然后经中线切口进入动脉瘤。发现右髂支延伸处的织物撕裂导致IIIb型内漏。尝试缝合未成功，随后使用Endurant II Limb（美国明尼苏达州明尼阿波利斯的美敦力公司）对病变进行内衬修复，成功修复了内漏。
IIIb型内漏不常见且易被漏诊，因为织物缺陷过小或间歇性渗漏。它们可模仿其他类型的内漏，并可能导致动脉瘤增大和破裂。如果先前对其他类型内漏的治疗失败，应考虑这种类型的内漏。
