A 67-year-old, with increasing abdominal aortic aneurism diameter 18 months after EVAR (aorto-bi-iliac stent graft). Follow-up CT showed a type II lumbar endoleak, inaccessible to an endovascular treatment. (a) CT showing posterior endoleak fed by a lumbar artery. (b) (AP) and (c) (lateral): Periprosthetic endosaccular access via a CT-guided transparietal puncture: injection of Onyx. Note the opacification of two lumbar arteries (arrows)

A 83-year-old M, EVAR (aortoiliac stent graft) 3 years ago to treat an infrarenal aortic abdominal aneurysm. An occlusion of the right leg after few weeks had led to a suprapubic left-right cross bypass. Annual CT follow-up has shown an increase in size of the sac. Which was caused by various endoleaks: type 1, due to a continuous growth in diameter of aorta above the stentgraft; type 2, via lumbar arteries, which seemed contingent; and finally suspected type 3 endoleak due to the imperfect coaptation between the aortic piece and the left iliac leg of the stent graft. (a) CT scan at the upper extremity of the stent graft, at the level of the ostium of the left renal artery (arrow). (b–d) Scans below the previous: endosaccular extra-prosthetic anterior enhancement (arrows), occluded right leg of the endoprosthesis (black arrow). (e, f) Sagittal CT reconstruction: type 1 endoleak; reconstruction passing through the right leg (3–6): type 3 endoleak. (g) Aortography conducted via a left humeral access (pigtail), a guidewire was also led via a left femoral access. Late phase (h): right endosaccular extra-prosthetic enhancement (arrow) (note the presence of a bone screw, from a previous spine surgery). (i, j) The type 1 endoleak was confirmed by selective catheterization, using a Mikaelsson catheter inserted between the proximal uncovered petals of the stent graft. (k) Coils (arrows) were positioned in the flowing phase of the endoleak; then a cuff (short cylindrical stent graft) was deployed at the upper neck. On this image, before the release of the cuff, note the ostium of the left renal artery catheterized by a guidewire brought via the humeral access. (l) Control after coiling and expansion of the cuff: exclusion of the type 1endoleak. (m, n) Type 3 endoleak is not clearly shown by the injections at the lower part of the aorta; occlusion of the left prosthetic branch; coils in the right hypogastric artery (that preceded the stent grafting implantation, to avoid reinjection); good patency of the left hypogastric artery, downstream of the stent graft; suprapubic left-right cross bypass. However, a complementary left iliac stent graft was deployed to cover the prosthetic aortoiliac anastomosis. (o, p) Final control opacification