PMC4857307_01
(a) Post-operative CT 3D reconstructions showing the initial aorto-bi-iliac Boston Vanguard graft. (b) Post-operative f-EVAR proximal extension.
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In 1998, a 71-year-old man underwent elective EVAR with an aorto-bi-iliac Vanguard Boston Scientific graft for a 5.5-cm diameter abdominal aortic aneurysm (AAA; Figure 1(a)). Re-intervention with a Cook  custom-made three-vessel fenestrated endograft (fenestrated endovascular aortic aneurysm repair (f-EVAR)) with an aortic cuff to bridge between the custom graft and the original Vanguard graft was successful (Figure 1(b)).
(a) Pre-operative CTA displaying AAA rupture with blood in the retroperitoneum and a type 3 endoleak (white arrow) from the left graft limb. (b) Post-operative CT 3D reconstruction showing final bilateral limb placements, leaving an 18-mm gap (blue arrow) only lined with initial Vanguard graft.
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CTA confirmed a ruptured AAA, secondary to a type 3 endoleak from left iliac limb failure (Figure 2(a)). Cook Spiral-Z limbs were inserted into the flow divider of the original Vanguard device with resolution of the patient's symptoms and restoration of hemodynamic stability. Completion angiogram and follow-up CTA showed no endoleaks and a sac size of 7 cm (Figure 2(b)).
(a) Pre-operative CT 3D reconstructions showing the 18-mm gap between the proximal f-EVAR and bilateral iliac limbs. (b) "Off-ended" orientation of the graft and its limbs can be appreciated in the lateral view. (c) Subsequent conversion to right aorto-uni-iliac stent with femoral-femoral artery bypass.
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CTA showed that the aneurysm sac had increased to 9 cm with a type 3 endoleak and a stent strut fracture of the original Vanguard device, in the 18-mm segment between the previously inserted aortic cuff and iliac limbs (Figure 3(a)). Although the patient initially experienced spontaneous resolution of symptoms, repeat CTA showed that the two iliac limbs were becoming increasingly "off-ended" from the main body (Figure 3(b)), probably due to the failure of the Vanguard graft between the new proximal extension device and the iliac limbs. Completion angiography confirmed successful exclusion of the left iliac limb, absence of endoleak, and excellent flow through the bypass (Figure 3(c)).