A hybrid approach to multiple endoleaks in a patient with situs inversus totalis

Abstract

Situs inversus totalis (SIT) is a rare congenital condition characterized by mirror image transposition of thoracic and abdominal organs. The coexistence of SIT and abdominal aortic aneurysm presents unique anatomical and surgical challenges. We reported a case of a 60-year-old male with SIT and a history of endovascular aneurysm repair who developed multiple endoleaks (T1bEL, T2EL, and T3EL). A hybrid procedure combining open surgical repair and endovascular techniques was successfully employed to address the complex endoleaks (ELs). The procedure included ligation of collateral vessels, stent-graft extension, and preservation of the right internal iliac artery using an artificial vessel. This case highlights the feasibility of a hybrid approach for managing ELs in patients with SIT and underscores the importance of tailored surgical strategies.

Keywords: abdominal aortic aneurysm; hybrid operation; multiple endoleaks; situs inversus totalis.

Figure 1

(a) Chest X-ray shows dextrocardia and dilation of the mediastinal shadow. (b) Contrast-enhanced computed tomography demonstrated a previous stent–graft placement, a type II endoleak with a giant aneurysm sac, a distal right common iliac artery dilatation with a type Ib endoleak. (c) Identification of a huge infrarenal aortic aneurysm through a mid-abdominal incision and was subsequently controlled with a sleeve to facilitate subsequent surgical procedures. (d) Angiography revealed a significant type Ib endoleak in the distal to the right common iliac branch. AA, abdominal aorta; CIA, common iliac artery; LRA, left renal artery; RRA, right renal artery; T1bEL, type 1b endoleak.

Figure 2

(a) Proximal angiography showed occlusion of the back-bleeding side branches leading to type II endoleak. (b) Distal angiography revealed an effective isolation of a type 1b endoleak in the right common iliac artery, but there was an absence of the right internal iliac artery. (c) After relining the graft with an additional branched iliac device, angiography confirmed the successful isolation of a type III endoleak, with no contrast leakage observed between the iliac branch and the main body of the stent graft. (d) No active bleeding was observed at the bilateral anastomoses or within the graft following the release of the aortic clamp. AV, artificial vessel; LCIA, left common iliac artery; LIB, left iliac branch; RCIA, right common iliac artery; REIA, right external iliac artery; RIB, right iliac branch.