Type III B endoleak leading to aortic rupture after endovascular repair: analysis of errors in follow up and treatment

BACKGROUND: 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. CASE PRESENTATION: 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. CONCLUSIONS: 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.