Progressive dysphagia and dyspnea after thoracic endovascular aortic repair due to a rare cause of type II endoleak

A 34-year-old man was admitted to a local hospital with progressively worsening dysphagia and dyspnea 3 weeks after thoracic endovascular aortic repair (TEVAR) of acute type B aortic dissection. Computed tomography angiography (CTA) showed a huge periaortic hematoma (77 mm × 63 mm, asterisk) resulting in severe compression of the esophagus and left trachea (A). The patient was rapidly transferred to our unit, and physical examination indicated diminished left chest breath sound. Although type I or III endoleak (red arrowhead) was initially suspected (B; Supplementary Video 1, online only), such diagnoses were excluded by the intraluminal aortography (Supplementary Video 2, online only). Further three-dimensional CTA identified a type II endoleak probably caused by two distant intercostal arteries uncommonly communicating through the false lumen (C/Cover). This particular diagnosis was supported by the findings of angiography via the false lumen (D; Supplementary Video 3, online only; yellow arrowheads indicate intercostal arteries). Two culprit intercostal vessels were embolized with coils through the false lumen approach. Completion angiography (Supplementary Video 4, online only) and postoperative CTA (Supplementary Video 5, online only) detected no residual endoleaks, the left tracheal compression and dyspnea were significantly relieved, and no spinal cord ischemia occurred. The patient was discharged to a rehabilitation center with nasogastric tube indwelling 1 week after surgery. Three-month follow-up showed that the patient was in good condition and returned to oral diet. Informed consent was obtained for publication of this case report and the accompanying images. The occurrence of type II endoleak after TEVAR is less common than that after abdominal endovascular repair (3.3%-8.7% vs 10%-44%).1Ameli-Renani S. Pavlidis V. Morgan R.A. Secondary endoleak management following TEVAR and EVAR.Cardiovasc Intervent Radiol. 2020; 43: 1839-1854Crossref PubMed Scopus (16) Google Scholar, 2Bischoff M.S. Geisbüsch P. Kotelis D. Müller-Eschner M. Hyhlik-Dürr A. Böckler D. Clinical significance of type II endoleaks after thoracic endovascular aortic repair.J Vasc Surg. 2013; 58: 643-650Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 3Gonzalez-Urquijo M. Lozano-Balderas G. Fabiani M.A. Type II endoleaks after EVAR: a literature review of current concepts.Vasc Endovascular Surg. 2020; 54: 718-724Crossref PubMed Scopus (4) Google Scholar Moreover, most type II endoleaks after TEVAR could resolve spontaneously, and reintervention rates were extremely low.1Ameli-Renani S. Pavlidis V. Morgan R.A. Secondary endoleak management following TEVAR and EVAR.Cardiovasc Intervent Radiol. 2020; 43: 1839-1854Crossref PubMed Scopus (16) Google Scholar,2Bischoff M.S. Geisbüsch P. Kotelis D. Müller-Eschner M. Hyhlik-Dürr A. Böckler D. Clinical significance of type II endoleaks after thoracic endovascular aortic repair.J Vasc Surg. 2013; 58: 643-650Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Esophagotracheal compression caused by continued perfusion of the false lumen due to unresolved type II endoleak is an exceptionally rare but lethal complication (eg, fistula, rupture, infection, etc) after TEVAR.4Luehr M. Etz C.D. Nozdrzykowski M. Garbade J. Lehmkuhl L. Schmidt A. et al.Emergency open surgery for aorto-oesophageal and aorto-bronchial fistulae after thoracic endovascular aortic repair: a single-centre experience.Eur J Cardiothorac Surg. 2015; 47: 374-382Crossref PubMed Scopus (27) Google Scholar Even more rare, this particular type II endoleak was caused by a patent communication between two distant intercostal arteries through the false lumen. Such condition requires accurate diagnosis and prompt reintervention. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIyN2IxMzRiMTRlNjlhY2M4ZTA2ZjQ0OTA2ZDQ0YjYxNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcxMDk1OTMyfQ.X9e-2l4E-yY2H74Y6EpBeQ4wsg8vkC92BcJxjT7hZgLkq8QVNvRzgyb0nCF0v7mOI3TpzSRUPWAYhGtbj6nLHWnwJQeTBRu4fEb3FVaLHmbq-OyQcT7og8ULcSCmBO06FXr1LH_oNVriV9rywn505UAAhsIS2LOfOsm7S0FlI0DHXmGtzSAPGSj4zqSzoZv92aPYxQ0SIus5Q2afko_GIYfKFv5IYf1zCKAEyzmZEY9GO8b0aeJYR9jDqe0Yduyw9QjKgFBsLBrIzBYUClIIzcVWBaSrwOH5l38ghaJzVZ2h6JTvJ-gH-r_ymzGKfEDGG69v5e4C9_7ilzpOa8J-ag Download .mp4 (5.76 MB) Help with .mp4 files Supplementary Video 1 (online only)Transverse view of preoperative computed tomography angiography (CTA) showed suspected type I or III endoleak (red arrowhead) after thoracic endovascular aortic repair (TEVAR).eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmY2E3ZDQ1MTMwNmNiNDdkZjI3ZDVlODgxODNhMWVhZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcxMDk1OTMyfQ.OkAtFyZXFfI7u3HXwGdwBzxmhGzaGRKY-NQVU0t9_SuAWecwdDrS68uevHydzAyyMdXxJ7fGx3C_J0UhZJYkk5a2DvaN49-KJfenZG3hux9fRH8lBUbPNBQWsD-V6G7gglgICmltEX7MNG_7GIbpuRyi2_s7wBrtqNZKkRPxtVtTduzPm5oN3hpUgwJ950OPV7lzLABTXLtcfsOzzYS7dGbeIY5-4rjVO7Gw9wSSTY-mRiv5ZAIAUoBevNBd9IzZKrbDbHkPZsMlseAoJxL-5_mN236s1VnEwtLy6PV6OUvQVaDBohGnOTn5Ngr8l8S9hlpWdamsd4kWxS9MV56U4w Download .mp4 (5.4 MB) Help with .mp4 files Supplementary Video 2 (online only)Intraluminal aortography excluded the diagnoses of type I or III endoleak.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxMjNhZGNiOWJhZjIzNWZkZDQ4OTk3Y2M3NWU0NzMyNCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcxMDk1OTMyfQ.TBqKEvS6xH9YCSyEFpV21cOkVAiqZwkgkMgnyxmZguuqYSs4SdOiZQwBdJJuLnNWA9l5QWrRl4uEF7UcdxeBrLYu8AGrfUC1vfg7Ynsa06FIPQlZnCu6pdmQtAHLN9aEVCbRKNWgLXoqbr9fms5Hl7Y10kOURlV52Uq_hQO2ggTNrrvMBZTPOuTErukVC8bJeGpRGFEeQ41pRq2pgwMSSw9TeJZMx9mCuNaGmIZrSccFODzryyvENcI7Lrv20O5nL-5WE1AtW4gibbCcHshE7nE2ZoOrPm-Ceh7qqFsQowCHmxnGVAyWmgLPNtR2q_hsk9o0TiLwEtCQv6C6XWKVJA Download .mp4 (5.66 MB) Help with .mp4 files Supplementary Video 3 (online only)Angiography via the false lumen revealed type II endoleak after thoracic endovascular aortic repair (TEVAR), caused by two intercostal arteries (yellow arrowheads). The red arrowhead indicates the suspected type I or III endoleak.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIwNjdmMzhiMmQyNWQzMTMzMDgxMWJjOWE3YTMxMjA0OCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcxMDk1OTMyfQ.YVRFVLFohPBHnao2--KK0DVTjDvZ7cuPrOLTJpINGEiH1FLWGWyok9Nlqp4UO7zQBNzGOSnUbrImEjLYvzUjpyg7dRgkzdTrV6EIk6eT_NXhWzoawMQSE7vl48pvx_jHFDJo4DcCEgn3PROv-RqKsFVTF6O_6JKkNx9_ViZn54WzNxUhENRDYnDXRBITE6qFp-kyT8J6ZCV0gSqxLtTgAFQSm56JrNFQxupg3NmTA9sjroQIIX-gwjQzd681yF2hRKBmFt7iMZ8tDqkd21lU0am1coUZ_sH2P5up6hSJF_oZ-sq8qj6NvyYgvScYqAvtEcJmTZV-CIW4N9JyWGcqYw Download .mp4 (2 MB) Help with .mp4 files Supplementary Video 4 (online only)Completion angiography demonstrated no residual endoleaks after coil embolization of the culprit vessels.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhMWE1YzIyODdmMmYzNDA0NTYwNjBjZjYzMzRiNmE3MSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcxMDk1OTMzfQ.khvAlksKaJpEG-uCLv-Yt83mDhxZ8ckKdZ_qbrM7p9wFrBLRXjRpSQ8wnk2SICEXBkNPz1QJUjHeKJpaXtSj_vsTFzOAqE1-XSFF-vqal7-Jtu0v9GOKMPMU5m13eZWYj8N_RFt3n0diQX-UpuAqVv-f4DmjR7Y_xyX4IFWtU9FZcy0WHkGpySbCQvsMBjgFrcErL_IJAKRaDKa1jMzX-znGRixB1w77tKJLtdBtLqDt4HXHctFDP4JN6wV5r7CaUwHo2gQ_IpFOvR9S0EgN1Bs3Nzq3WyH3UNseH_BnOPI3BFQoOR2-JxlnXAUBfcS4x3bn5Mn8r9cEjrN93XDlEw Download .mp4 (5.78 MB) Help with .mp4 files Supplementary Video 5 (online only)Transverse view of postoperative computed tomography angiography (CTA) detected no residual endoleaks.