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The patients suffered from coronary triple vessel disease and a history of an emergency coronary artery bypass grafting due to hemopericardium during percutaneous coronary intervention in 2004. She went subtotal gastrectomy operation in 2021 beacause of gastric cancer and she had a dyslipidemia. Physical exam revealed vital signs within normal limits, a blood pressure of 116/61 mmHg, heart rate of 71 bpm. 

Laboratory testing demonstrated a hemoglobin level of 12.7 g/dl (normal 12.0 - 15.0 mg/dl), creatinine level of 0.69 mg/dl (normal 0.40 - 0.90 mg/dl), a HbA1c level of 6.4 %  (normal 4.0 - 6.0 %) and a LDL cholesterol level of 84 mg/dl (normal 40 - 130 mg/dl). The aneurysm size was 34.7 mm in May 2018 (Figure 1) and increased gradually to 40.2 mm in 2019 (Figure 2), 44.9 mm in August 2021 and 50 mm in May 2022 (Figure 3).

The bilateral femoral arteries were punctured and pre-closed with a perclose device. Baseline angiography revealed fusiform infrarenal aneurysm (Figure 4). We performed conventional EVAR main body implantation via the ipsilateral femoral artery. Before the contralateral limb implantation, a second vascular access was completed via the contralateral femoral artery and we positioned a 5Fr Cobra catheter tip in the middle portion of the aneurysmal sac in preparation of coil embolization (Figure 5).

The lateral limb and main body extension were successfully implanted, routine angioplasty with a compliant balloon to the proximal landing zone, and to the stent-graft overlap portion was completed. Aortography revealed a mixed type I and II endoleak (Figure 6). We performed additional angioplasty with a compliant balloon followed by endo-stapling with an endoanchor device (Heli-Fx EndoAnchor Medtronic Inc., Minneapolis, MN, US)(Figure 7) to the proximal landing zone. However, follow-up angiography revealed persistence of the endoleak. Therefore, we decided to perform coil embolization of the aneurysmal sac using a platinum coil (0.035-in Nester Platinum coil; Cook Medical, Bloomington, IN, US) via the pre-positioned 5Fr Cook Renal Access Cobra catheter. After the coil embolization, the final angiography showed complete exclusion of the aneurysmal sac. The next day, a follow-up computed tomography scan showed no significant endoleak (Figure 8). The patient is currently doing well without any vascular complications.

The simultaneous coil embolization via percutaneous trans-femoral artery approach is a promising technique for treating persistent type I and II mixed type endoleak despite angioplasty with a compliant balloon and endoanchor proximal landing zone approximation therapy.