Repair of a complex post-EVAR type III endoleak using a chimney aortouniiliac stent graft and femorofemoral crossover bypass
An 81-year-old gentleman with a background of ischaemic heart disease, hypertension, hyperlipidaemia, polycystic kidney disease and previous right hemicolectomy for bleeding diverticular disease, underwent EVAR 10 years ago. He was on yearly follow-up with computed tomography (CT) scan and latest CT in 2012 showed a type III endoleak with aneurysmal sac of 10 cm in size. Both common iliac arteries were long and tortuous. He was electively admitted for a diagnostic calibrating aortogram in our CT hybrid angiography suite (Toshiba Infinix VC-i). Intra-operatively, digital subtraction angiography (Fig. ) showed significant type IIIa endoleak with component separation on the left iliac limb. The old stent graft was <20 mm away from the left renal artery proximally (lowest visceral artery). He was discharged the next day and re-admitted 2 weeks later for a staged operation. Decision was made for a combination of left renal artery chimney, aortouniiliac stent grafting and femorofemoral crossover bypass.\nSurgery was performed in hybrid operating theatre. The aorta was accessed via bilateral groin cut-downs to expose both common femoral arteries. Intra-operatively, the type IIIa endoleak was excluded using a right-sided Cook aortouniiliac stent graft (AX1-1-36-116). The left renal arteries were cannulated from the left brachial artery. A PTFE-covered nitinol stent (Atrium V12) was advanced into the left renal artery and deployed in a chimney fashion. The left iliac limb of the stent was occluded using a 20 mm Amplatzer plug proximally and distally with Iliac Plug Zip 24 and 30 mm. Femorofemoral crossover bypass was then performed to complete the surgery. The completion angiography showed adequate sealing with no endoleak (Figs and ).