Sac Expansion with Vasa Vasorum-Related Type II Endoleak after Endovascular Aortic Repair Managed by Translumbar Direct Sac Embolization Using Glue

Abstract

An 84-year-old man with an abdominal aortic aneurysm with a largest diameter of 50 mm was treated using endovascular aortic repair (EVAR) within the instructions for use. Computed tomography (CT) performed 3 years after the EVAR revealed significant sac expansion. The first (3 years after EVAR) and second (4 years after EVAR) transarterial embolizations demonstrated rare type II endoleaks from the vasa vasorum as multiple fluffy contrast blushes from the aortic tributaries. As sac expansion persisted at 5 years after the EVAR, translumbar direct puncture of the sac and embolization using a mixture of 25% n-butyl cyanoacrylate and lipiodol was performed. A follow-up CT 2 years after the last embolization showed sac stability without any complications.

Intraoperative Findings of an Atypical Type II Endoleak from an Artery within the Aneurysmal Wall after Endovascular Aneurysm Repair

“…6) Two reports exist regarding the involvement of the vasa vasorum in aneurysmal enlargement as an atypical type II endoleak after EVAR, and both were treated with endovascular therapy. 1,2) To the naked eye, an endoleak from the vasa vasorum might appear to be from an artery within the aneurysmal wall, as in the present case. The second possible candidate vessel is that this was an anatomical variation, an abdominal aortic branch vessel running not outside but inside the aortic wall, following an intramural course.…”

“…Conversely, if the vessel was part of the vasa vasorum, whether this treatment would be the optimal management is unclear. In the reports of atypical type II endoleaks from vasa vasorum described earlier, 1,2) endovascular treatment with arterial embolization was performed; however, its effectiveness remains unknown because one case experienced recurrence, which was successfully treated with the translumbar direct sac embolization after failed arterial embolization. 2) In addition, the post-treatment condition of other patients was not described sufficiently.…”

“…In the reports of atypical type II endoleaks from vasa vasorum described earlier, 1,2) endovascular treatment with arterial embolization was performed; however, its effectiveness remains unknown because one case experienced recurrence, which was successfully treated with the translumbar direct sac embolization after failed arterial embolization. 2) In addition, the post-treatment condition of other patients was not described sufficiently. 1) Reports exist regarding the involvement of aneurysmal thrombus 6) or a hypoxic environment 8) in the development of vasa vasorum endoleaks after EVAR.…”

“…However, only two reports exist of the atypical type II endoleak not from an aortic branch, in which the vessel would be vasa vasorum, and both were subjected to endovascular treatment. 1,2) Herein, we performed late open conversion after EVAR and experienced not only typical type II endoleaks from the lumbar and median sacral artery but also atypical type II endoleak from an artery within the aneurysmal wall with no inflow blood vessels outside the aneurysm.…”