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Relevant clinical history and physical exam
An 84-year-old female received endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) expanded to a diameter of 74 mm. The size of an aneurysm enlarged to 82 mm in diameter 1 year later. Angiography revealed that the bilateral lumbar arteries fed an aneurysm, and then we performed embolization for them at the level of L4 by using coils. After 2 years of EVAR, however, the size of an aneurysm expanded to a diameter of 90 mm. Thus, we tried to embolize collateral arteries again.
Relevant test results prior to catheterization
Although, after 1 year of first embolization, enhanced CT showed the inflow of contrast, the original arteries can not be identified. In addition; a signal of blood flow from the graft to an aneurysm was not detected by ultrasonography. Therefore, we suspected the presence of the feeding artery that is type 2 endoleak, although CT could not reveal that.
Relevant catheterization findings:
We performed angiography at both lumbar arteries which had already embolized before and noted the flow of left lumbar artery into AAA. Therefore, we performed embolization of that feeding artery and confirmed disappearance of the flow into AAA by final angiography. However, enhanced-CT also showed an inflow of contrast in an aneurysm next day. Because enhanced CT could not identify collateral sources, we performed angiography again to detect original arteries of collateral sources. It was difficult to identify the feeding artery, although we performed selective angiography for major arteries arising from the abdominal aorta. Eventually, we noticed that the small and narrow collateral artery fed an aneurysm. We embolized the collateral sources using coils and confirmed the endoleak was disappeared.
Type 2 endoleak is not interfered positively in general because it often regresses by itself. When it gets larger, CT helps us to identify the origin of collateral. However, CT is useless when the feeding artery is small like this case. In this case, We engaged catheter in each side branch of aortic artery and a small vessel arising directly from the abdominal aorta and succeeded in embolizing it.