Successful Management of a Type B Gutter Related Endoleak after Chimney EVAR by Coil Assisted Onyx Embolisation

Introduction: The aim was to describe possible management of a persistent gutter related type Ia endoleak after treatment of a symptomatic pararenal aortic aneurysm with the chimney endovascular technique. Report: A 77 year old man with a symptomatic 6 cm pararenal aortic aneurysm was referred. Computed tomography angiography (CTA) showed a pararenal aortic aneurysm with involvement of both renal arteries and extension up to the superior mesenteric artery. The patient underwent treatment by placement of triple chimney grafts and an abdominal stent graft. Completion angiography showed a gutter related type Ia endoleak. As the type Ia endoleak persisted at the three month CTA follow up and according to the PERICLES registry classification of endoleaks, a type B causative mechanism was detected. Embolization of the gutters was performed with coils and onyx, leading to complete resolution of the gutters on completion angiography. The 10 month post-operative magnetic resonance angiogram showed no further evidence of any endoleak and complete exclusion of the aneurysm. Conclusion: Treatment of persistent type B gutter related endoleaks after triple chimney endovascular aneurysm repair can be performed with the placement of coils and adjunctive use of fluid agents. Keywords: Chimney stent graft, Computed tomographic angiography, Endoleak, Endovascular aneurysm repair, Pararenal aneurys