Background: Endovascular Aneurysm Repair (EVAR) has been a long-stay surgical option to treat abdominal aortic aneurysms (AAA), both contained and ruptured. Endoleaks, defined as persistent flow in the aneurysm sac extrinsic to the endograft, is the most common complication. Type II endoleak (T2EL) results from collateral aortic branches (mainly lumbar arteries, inferior mesenteric artery) flowing retrogradely into the sac. It is often considered the Achilles' heel to EVAR due to the controversies in its timing of diagnosis and management. It is generally accepted that T2EL are slow growing, could expand the aneurysm sac, and carry a small but significant risk of aneurysm rupture.

Case Presentation: This case reports an early post-EVAR complication due to T2EL.

A 66-year-old man was brought to casualty hypotensive, minimally responsive with a rigid and tender abdomen. CT Angiography revealed a ruptured AAA contained within the retro peritoneum. The patient subsequently underwent an uncomplicated EVAR procedure. However, one-hour post procedure in ICU, he was found to be suddenly in haemorrhagic shock. Open conversion via exploratory laparotomy revealed 5L of blood within the peritoneum. Aneurysm sac was opened and four strong bleeding lumbar arteries were identified and oversewn to control the bleeding. It has hypothesised that vigorous T2EL from lumbar back-bleed, through the ruptured aneurysm sac led to ongoing bleeding into the contained retroperitoneum and subsequently secondary “rupture” into the peritoneal cavity.

Conclusion: This case showed that T2EL are not all slow growing and innocuous. One should consider T2EL as a cause of a patient who is acutely deteriorating post-EVAR. Early CT-angiographic imaging post procedure may be indicated in certain groups.