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Type III Endoleak Resulting From a Fractured Renal Stent in a Patient with Branched Endograft
Carlos Rivera, MD, Cindy Sturt, MD, Michael Addis, MD, Adam Sagarwala, DO, Pratish Majundar, BS, Bruce J. Brener, MD.
Newark Beth Israel Med Ctr, Newark, NJ, USA.

Background:
Fenestrated grafts used for aneurysms originating 4 mm below the renal arteries are available in the United States. Fenestrated and branched grafts for extensive thoracoabdominal aneurysms are not marketed in the US but several centers have employed either surgeon-modified or company-manufactured grafts sporadically or as part of sponsored IDEs. We report a patient with a Type III endoleak resulting from fracture and perforation of a covered renal stent used to treat a thoracoabdominal aneurysm.
Case Report:
A 75 year old man presented in the emergency department with severe back pain. In 1989, he was treated for a ruptured abdominal aneurysm with open repair. In 1997, a Type A aortic dissection was repaired. He developed a thoracoabdominal aneurysm and was admitted to Cleveland Clinic 2012. He underwent staged repair of femoral artery aneurysms and placement of a fenestrated four vessel branched custom made endograft (Cook) as part of an investigator sponsored IDE. The right renal branch consisted of two overlapping Jomed covered stents. The patient developed perioperative paraplegia. In 2013, a computer tomographic angiogram (CTA) showed a 4.5 cm thoracoabdominal aneurysm with patent branches and no endoleak. In January 2016, a CTA revealed a 7.5 cm thoracoabdominal aneurysm with a significant leak. The patient was initially treated with an additional left renal covered stent protruding into the main body of the graft and angioplasty of the right renal stent. Repeat angiography indicated a leak through the right renal covered stent as a result of stent fracture and perforation of the fabric. The right renal graft was relined with a 6x38 iCast stent, resulting in resolution of the leak.
Conclusions:
The superiority of directional branches versus fenestrated branches is currently being debated. The mechanism of branch related endoleaks needs to be evaluated and proper technology developed to eliminate leaks and provide patency.


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