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      Atypical Presentation of a Type 2 Endoleak following Emergency Open Repair of a Ruptured Abdominal Aortic Aneurysm

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          Abstract

          Background

          An endoleak is a common complication following EVAR. Specifically, a Type 2 endoleak occurs because of retrograde flow from lumbar vessels outside the endograft within the aneurysm sac. Even though it is common following EVAR, it has not been identified as a complication following open ruptured abdominal aortic aneurysm (AAA) repair.

          Report

          A 73-year-old male underwent open repair of a ruptured AAA. Five months later, computed tomography revealed filling from a lumbar vessel mimicking a Type 2 “endoleak.” The initial ultrasound showed a single pair of lumbar vessels with aneurysm sac expansion 8 weeks later. The “endoleak” and expanding sac were treated, and the 2-year surveillance demonstrated sac shrinkage.

          Discussion

          Because endoleak is a complication after EVAR, this case provides a unique presentation of Type 2 “endoleak” physiology following open repair of a ruptured AAA. It is believed that it is necessary to expand the list of possible complications after open ruptured AAA repair to include “endoleaks.”

          Highlights

          • An endoleak is a common complication observed after EVAR, but not open AAA repair.

          • Type 2 endoleak after open AAA repair has a similar treatment paradigm to EVAR.

          • Translumbar embolization done utilized bony landmarks without endograft as landmark.

          • Endoleak is a complication of EVAR, but open AAA repair can mimic similar pathology.

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          Most cited references5

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          Outcome of popliteal artery aneurysms after exclusion and bypass: significance of residual patent branches mimicking type II endoleaks.

          Popliteal aneurysms (PAs) often are treated with exclusion and bypass. However, excluded aneurysms can transmit systemic pressure from persistent flow through collateral arteries (endoleak), resulting in aneurysm growth and rupture. We used duplex ultrasound scanning for postoperative surveillance more than 2 years after PA repair with exclusion and bypass, to determine the presence of flow and aneurysm growth.
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            Management of type II endoleaks: preoperative versus postoperative versus expectant management.

            Type II endoleak is a common phenomenon after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Most type II endoleaks are innocuous and transient and therefore do not require intervention. However, particularly persistent endoleaks could lead to aneurysm enlargement and delayed aortic rupture. Decreasing the occurrence rates of type II endoleaks can be attempted with prophylactic occlusion of the inferior mesenteric, hypogastric, and lumbar arteries. Although the efficacy and clinical benefit of prophylactic occlusion of aortic branches prior to EVAR or during the endovascular repair remain controversial, we anticipate an increased use of intraoperative embolization techniques. A reasonable treatment strategy in patients with type II endoleak may be to intervene in cases of increasing aneurysm size or if the endoleak does not resolve spontaneously within 6 months. Translumbar embolization has been shown to be more effective than transarterial embolization. An alternative embolization technique is transcaval embolization, which has shown success rates comparable to translumbar embolization. Type II endoleaks can also be treated during laparoscopy or laparotomy, but these techniques are more invasive and should be used only after failure of embolization techniques.
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              Treatment of an early type II endoleak causing hemorrhage after endovascular aneurysm repair for ruptured abdominal aortic aneurysm.

              We report a case of ruptured abdominal aortic aneurysm emergently treated by endovascular aneurysm repair (EVAR) that developed a primary type II endoleak leading to persistent blood loss and retroperitoneal hematoma increase. Coil embolization resolved this. Although to our knowledge there are no recommendations regarding this, our report suggests that early type II endoleaks occurring after emergency EVAR for ruptured AAA should be treated when it is associated with blood extravasation outside the aneurysm sac.
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                Author and article information

                Contributors
                Journal
                EJVES Short Rep
                EJVES Short Rep
                EJVES Short Reports
                Elsevier
                2405-6553
                10 October 2016
                2016
                10 October 2016
                : 33
                : 24-26
                Affiliations
                [a ]Central Michigan University College of Medicine, Mount Pleasant, MI, USA
                [b ]Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL, USA
                [c ]Section of Vascular Surgery and Endovascular Therapy, University of Chicago Medical Center, Chicago, IL, USA
                Author notes
                []Corresponding author. Central Michigan University College of Medicine, 1280 East Campus Drive, Mount Pleasant, MI 48859, USA.Central Michigan University College of Medicine1280 East Campus DriveMount PleasantMI48859USA sharm1kj@ 123456cmich.edu
                Article
                S2405-6553(16)30022-6
                10.1016/j.ejvssr.2016.09.002
                5576093
                ea8890f4-0c8e-4a65-8f2b-af648685e77d
                © 2016 The Author(s)

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 28 July 2016
                : 5 September 2016
                : 7 September 2016
                Categories
                Case Report

                endoleak: evar,ruptured aneurysm,open abdominal aortic aneurysm

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