PMC5307129_01
Computed tomography angiogram of ruptured AAA at initial presentation to the emergency department. (a) Three-dimensional reconstruction of the aneurysm sac. (b) Corresponding cross-sectional demonstrating rupture of AAA with active extravasation of contrast into the retroperitoneum.
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She presented to the emergency department with severe abdominal and back pain and hypotension and was found on CT angiography to have a contained rupture of her infrarenal aneurysm that measured 7.9 cm in diameter and had significant proximal neck and iliac angulation (Figure 1).
Intraoperative aortogram at the initial procedure showing the correct placement of the endograft and limbs bilaterally.
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At the completion arteriogram, no endoleak was identified and the distal ends of the iliac limbs were confirmed with a centimeter within the bifurcation of the iliac arteries (Figure 2).
Computed tomography angiography performed on postoperative day 2 demonstrating the proximal migration of the right endograft limb (arrow).
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Further review of the CTA demonstrated proximal migration of the right limb with a significant decrease in the length of the seal zone (Figure 3).
Intraoperative angiogram on postoperative day 2 demonstrating the acute proximal migration in the right common iliac artery resulting from the large aneurysm sac and the postimplantation change of the aortic anatomy.
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The patient was immediately transferred to the operating room and a retrograde arteriogram confirmed the right type 1b endoleak (Figure 4).
Follow-up at 12 months demonstrates a proximal migration of the left endograft limb (asterisk) on three-dimensional reconstruction of the CTA (a), leading to a type 1b endoleak as demonstrated in the aortogram (b).
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Proximal migration of the left limb of the endograft was documented by comparison of the 12-month CTA images to the intraoperative arteriogram during the original repair and the subsequent CTA images at 1 and 6 months (Figure 5).
Surveillance follow-up CTA at 18 months. Three-dimensional reconstruction demonstrates the correct placement of the bilateral iliac limbs at the seal zones without evidence of endoleaks.
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A CT angiogram 6 months later confirmed complete resolution of the type 1b endoleak and a stable size of the aneurysm sac (Figure 6).