There is little published data on the incidence, management or risk of rupture associated with Type II endoleaks following endovascular treatment of IAAs. Some of the principles of management are inferred from the published data on endovascular repair of abdominal aneurysms. Although most experts in the field consider Type II endoleaks to have a benign course [9
], in some cases they assume clinical significance particularly when they remain after six months or appear de novo
resulting in aneurysm sac expansion. In our case, sac expansion due to continued filling from branch vessels led to rupture, although the overall risk of this is low [5
]. Therefore, most authors advocate patients with Type II endoleaks following endovascular repair of an IAA should be managed conservatively unless there is evidence of enlargement of the aneurysm sac [5
Treatment options include percutaneous transluminal coil embolisation [11
], intra-arterial embolisation [12
], and—more specifically in the case of IAAs—percutaneous transosseous embolisation [13
]. The technique of laparoscopic branch ligation has been suggested as an alternative for the treatment of Type II endoleaks by some experienced investigators [14
], particularly in cases of failed embolisation. Open ligation is rarely used and only indicated when all other approaches have failed.
The incidence of Type II endoleak following iliac artery repair is around 15% [5
] even with routine coil embolisation of distal vessels pre-stent insertion. Ruptures secondary to Type I endoleak [6
] and Type III endoleak [15
] following endovascular repair of an IAA have been previously described but, to our knowledge, we are the first to report rupture following a Type II leak. In our case there was no intravascular transfemoral route to embolise the endoleak. Open or laparoscopic ligation was not considered owing to patient age and comorbidities. Therefore, we resorted to a novel approach and successfully performed a transcutaneous direct puncture and embolisation of the superior gluteal artery. To our knowledge this has never before been described in this type of aneurysm. Surveillance is essential to detect endoleaks early and we adopt a combined approach using CT angiogram and six monthly duplex ultrasound, which has been shown to have a high sensitivity at detecting endoleaks [16
]. Overall we feel the best approach to treatment of Type II endoleaks is one that is safe, effective and tailored to the specific circumstances and anatomy of the patient. Although rupture of IAAs is rare, particularly after Type II endoleak, a high degree of suspicion is essential to correctly diagnose and manage this condition.