Relining of infrarenal stent-graft with preloaded modified Gore Excluder for occult endoleak with sac expansion

Endoleaks remain one of the most common indications for reintervention after endovascular aortic repair. Occasionally, aneurysm sac expansion will occur in the absence of a visible endoleak or due to endotension. We describe a case of continued sac expansion without an identifiable endoleak after endovascular aortic repair. Technical challenges during the case included a short distance from the renal arteries to the flow divider and a significant metal artifact. These challenges were addressed by shortening the gate of a Gore Excluder (W.L. Gore & Associates, Flagstaff, Ariz) to the desired length. The contralateral gate was preloaded to allow for use of the snare-ride technique for gate cannulation and overcome the metal artifact that was hindering visualization.