PMC9030361_01
Initial endoleak diagnosis after endovascular aortic aneurysm repair. Axial Color Doppler US (a) and axial arterial phase computed tomography angiogram (b) showing endoleak at the anterior margin of the aneurysm sac (arrow), near the IMA origin, suggesting Type 2 endoleak. Polycystic kidney disease also seen
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F1
Ten months later, follow-up duplex ultrasound showed a new endoleak at the anterior aspect of the sac [Figure 1a] which was confirmed with CTA with pooling of contrast during the arterial phase of imaging at the anterior aspect of the aneurysm sac [Figure 1b].
Follow-up endoleak imaging. Axial arterial phase computed tomography angiogram (a) showing endoleak anteriorly (arrow) and posteriorly (arrowhead). Sagittal color Doppler US (b) showing endoleak spanning anteroposterior dimension of the sac. Preoperative axial contrast enhanced ultrasound (c) showing a delayed endoleak (arrow), appearing 11 s after endograft (E) opacification. Sagittal contrast-enhanced ultrasound (d) demonstrating inflow from right lumbar artery (arrows)
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F2
The patient underwent repeat imaging with CTA [Figure 2a] and duplex US [Figure 2b] which showed the aneurysm sac had increased in size, now measuring 6.3 cm, with persistent endoleak that had changed morphology. Inc., Monroe Township NJ, USA) was injected, followed by a 5 mL sterile saline flush. Imaging was performed through the aneurysm sac, to verify that a leak was present [Figure 2c]. Sagittal imaging was also utilized to confirm a posterior inflow vessel [Figure 2d] a right lumbar artery.
Angiographic procedure. (a) Right internal iliac arteriogram showing endoleak nidus (star) with right L3 lumbar artery inflow (arrow). (b) Selective right L3 lumbar arteriogram showing inflow, nidus, and left L3 lumbar artery outflow (arrowhead). (c) Postembolization angiography demonstrating endoleak occlusion
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F3
The right internal iliac angiography demonstrated an arterial collateral pathway arising from the right iliolumbar artery, which reconstituted the right L3 lumbar artery that supplied the arterial nidus of the endoleak [Figure 3a]. A coaxial microcatheter system was used to select the arterial inflow of the right L3 lumbar artery, and superselective angiography confirmed supply to the nidus and also identified the left L3 lumbar artery as the outflow vessel [Figure 3b]. The microcatheter system was used to select and embolize the outflow vessel, nidus, and inflow vessel with postembolization angiography demonstrating stasis through the nidus and treated vessels [Figure 3c].