Endovascular repair of a type IA endoleak following ALTO endograft placement using a custom-made fenestrated device

<h2>Abstract</h2> The ALTO endograft (Endologix Inc.) was developed to expand endovascular aneurysm repair (EVAR) eligibility. However, type IA endoleak remains a devastating complication associated with this device. Few reports describe management of endoleaks after ALTO implantation, and published cases are limited to open surgical explantation. We report a case of type IA endoleak following EVAR using an ALTO device, which was successfully treated with a custom-made three-fenestration endograft with an integrated bifurcation. The procedure was performed with fusion imaging and carbon dioxide angiography. Technical success was achieved. One-year follow-up imaging demonstrated no residual proximal endoleak nor aneurysm sac enlargement.