Open Repair of Type III Endoleak after Fenestrated EVAR
Marilisa Soto Gonzalez, MD, David Timaran, MD, Martyn Knowles, MD, Shirling Tsai, MD, Carlos Timaran, MD, John Rectenwald, MD, J. Gregory Modrall, MD.
UTSW, DALLAS, TX, USA.
OBJECTIVES: Severe angulation of the infrarenal neck can result in mal-opposition between the proximal fenestrated component and the bifurcated device, leading to type III endoleak after fenestrated EVAR (FEVAR). We describe a technique for open repair of type III endoleak after FEVAR in patients with no other endovascular options.
METHODS: Two patients with type III endoleak after FEVAR for juxtarenal AAA were identified. Both patients had juxtarenal AAAs with severely angulated infrarenal necks. Procedural details are described.
RESULTS: A 59 year-old male with significant coronary artery disease and heart failure underwent FEVAR. Another frail 84 year-old male underwent FEVAR after standard EVAR was complicated by type I endoleak. In both cases, mal-apposition of the fenestrated and bifurcated devices resulted in type III endoleak that was not amenable to endovascular salvage. Careful review of the pre-operative CT angiogram in each case confirmed that there was proximal seal in the fenestrated component as well as distal seal in the iliac limbs. We therefore proposed repair with an infrarenal aortic clamp, preserving the fenestrated cuff and the iliac limbs, and replacing the mal-opposed components of the endograft with a bifurcated Dacron graft. This would spare the patients a suprarenal clamp and also the highly morbid procedure of removing the visceral stents in the FEVAR. After the aneurysm sac was opened, the Iliac limbs were divided with wire cutters. The mal-opposed endograft components were resected, leaving just the fenestrated cuff and the distal iliac limbs (Figure A). A bifurcated Dacron graft was sewn in as an interposition graft (Figure B). Both patients recovered with minimal complications. Follow-up CT angiograms at 30 days and 1 year revealed widely patent visceral artery stents and no evidence of endoleak.
CONCLUSIONS: Open repair of Type III endoleak after FEVAR preserving the fenestrated cuff and iliac limbs intact is an alternative for select patients not eligible for further endovascular salvage of the aortic endograft and can successfully be accomplished with minimal morbidity and mortality. 
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