Management of Complex Endoleak From Endovascular Graft Component Separation in the Thoracoabdominal Aorta

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BACKGROUND: Type IIIa endoleaks are rare but critical complications of endovascular thoracoabdominal aortic repair, arising from graft component separation and requiring urgent intervention to prevent aneurysm sac enlargement and rupture. CASE SUMMARY: We present a 75-year-old man with a Crawford extent II thoracoabdominal aneurysm and a decade-long history of complex aortic interventions. He developed a persistent type IIIa endoleak from component separation of the left renal branch of his Zenith Fenestrated graft along with chimney graft migration, leading to sac expansion to 8.8 cm. Using 2 physician-modified endograft platforms, we successfully linked multiple prior graft systems while maintaining visceral branch perfusion. DISCUSSIONS: Component separation is a rare but critical long-term complication of endovascular thoracoabdominal aortic repair, requiring open or endovascular intervention to exclude the leaking component and maintain visceral patency. As complex thoracoabdominal aortic pathologies evolve, rigorous follow-up and multidisciplinary collaboration are needed to assess and manage complications arising from sophisticated endograft interventions. TAKE-HOME MESSAGE: This case highlights the unique set of challenges in managing endoleaks in patients with multiple aortic implants as well as the value of physician-modified grafts when standard endograft devices are precluded and open surgical techniques are prohibitive.

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