Endovascular Rescue of Type III Endoleak From an Abandoned Fenestration After Fenestrated Endovascular Aneurysm Repair.

BACKGROUND: Type III endoleak after fenestrated endovascular aneurysm repair of an abdominal aortic aneurysm is uncommon and difficult to treat when direct sac catheterization is not feasible. CASE SUMMARY: A 78-year-old man presented 1 year after fenestrated endovascular aneurysm repair with 4 fenestrations. During the initial procedure, a fenestration for a right accessory renal artery could not be bridged and was occluded with an embolization device, leaving an abandoned fenestration. Follow-up computed tomography angiography showed sac enlargement, perigraft contrast, and perianeurysmal high attenuation fluid, consistent with type III endoleak. Transgraft sac access was achieved with dual steerable sheaths and a puncture needle, followed by coil embolization and relining with a modified stent graft. Computed tomography angiography 2 weeks later showed marked reduction of the endoleak. DISCUSSION: The abandoned fenestration was the likely source of late type III endoleak, and transgraft puncture enabled controlled access to an otherwise inaccessible cavity. TAKE-HOME MESSAGE: Transgraft puncture, coil embolization, and stent graft relining may provide a feasible rescue strategy for selected cases.