“Sealing the Breach”: Endovascular Plug Repair of a Post-FEVAR Fabric Defect

BACKGROUND: Fenestrated endovascular aortic repair (FEVAR) is an established and effective treatment for thoracoabdominal aortic aneurysms (TAAAs). Although secondary endovascular interventions are not uncommon during follow-up, device-related failures causing type III endoleaks are rare but potentially life-threatening. When these defects occur within the visceral segment, standard relining techniques may be unfeasible, requiring alternative endovascular strategies to avoid open conversion. CASE PRESENTATION: A 73-year-old man, previously treated with a custom-made FEVAR, presented 3 years after the index procedure with severe back pain. Urgent computed tomography angiography revealed a large endoleak in the visceral segment, associated with aneurysm sac expansion and contained rupture. After relining of the superior mesenteric artery and the left renal artery, a type III endoleak originating from a small fabric defect between these vessels was identified and selectively catheterized. The defect was successfully treated by deploying an Amplatzer Vascular Plug IV across the graft tear. RESULTS: Completion angiography demonstrated near-complete exclusion of the endoleak. Follow-up imaging confirmed progressive aneurysm sac shrinkage and full endoleak resolution at 1 year, with preserved visceral and renal perfusion. CONCLUSION: In selective settings, plug embolization represents a practical and durable bailout option for type III endoleaks caused by small fabric disruptions after FEVAR, especially when conventional relining is not feasible. This approach enables rapid hemodynamic stabilization and offers favorable mid-term outcomes in high-risk patients.Clinical ImpactType IIIb endoleaks caused by fabric disruption after FEVAR are rare but potentially catastrophic complications that may lead to aneurysm rupture and require urgent treatment. When the defect is located within the fenestrated visceral segment, conventional relining techniques may be technically unfeasible or risk compromising target vessel perfusion. This report describes a novel bailout strategy based on selective catheterization of the graft defect and deployment of an Amplatzer Vascular Plug IV directly across the fabric tear. The technique allowed exclusion of the endoleak and preservation of visceral branch patency, expanding the endovascular armamentarium.