Preservation of Stent-Graft after Iatrogenic Type III Endoleak during Open Transperitoneal Surgical Intervention for Complicated Type II Endoleak.

Background: The use of an endovascular approach for treatment of abdominal aortic aneurysms has gained traction over the past 2 decades. One of the major drawbacks of the endovascular approach is the increased rates of reintervention, with the majority arising from endoleaks that occur up to 20% of the time. Although type II endoleak is the most common subtype (25-45% of all endoleaks), it is associated with the greatest dilemma and debate with regard to indications and modalities of treatment. The open surgical approach to management of type II endoleak has gained interest and popularity over the years because of issues associated with the endovascular approach. Methods: We present a case of a patient with type II endoleak undergoing transperitoneal sacotomy, endoaneurysmorrhaphy, and stent-graft preservation, after having failed endovascular intervention. In addition, we describe the difficulties associated with posteriorly located backbleeding lumbar arteries and a unique case of iatrogenically created type III endoleak intraoperatively. Results: A literature review was performed with regard to the risk factors, indications for intervention, and modalities of treatment for type II endoleaks. In addition, suggestions are provided for future improvements in surgical technique. Conclusions: Type II endoleak is a common complication of endovascular aortic repair. In spite of this, management strategies are poorly standardized with no definitive gold standard. More collective data and pooled experience will be needed to further refine the open surgical technique and objectively assess its benefits and shortcomings vis-a-vis other alternatives.