Abstract
Background
Complete thrombosis of an aortic endograft after an endovascular aortic aneurysm repair is a rare complication. The majority of thrombotic events occur in the iliac limbs.
Case presentation
We present the case of a patient who presented with acute limb ischemia as the result of a thrombosed infra-renal aortic endograft. After restoration of blood flow to the lower extremities with an axillary to bi-femoral artery bypass, the patient was lost to follow-up. The patient returned two years later with a ruptured abdominal aortic aneurysm due to a type 1A endoleak.
Discussion
We propose that all patients after endovascular aortic aneurysm repair, including those with a thrombosed aortic endograft, continue to undergo regular graft surveillance. This case report highlights the importance of continued surveillance of the aortic sac, even after total thrombosis of the endovascular aortic aneurysm repair.
Keywords
A 71-year-old male presented to the emergency room with the complaint of an acutely painful, ischemic, and paralyzed right lower extremity. His medical and surgical history was significant for a 7 cm abdominal aortic aneurysm (AAA) and an aortic endograft placed three months earlier at an outside hospital. An abdominal duplex was performed, demonstrating thrombosis of the endovascular aortic aneurysm repair (EVAR). The patient was taken emergently to the operating room, where a contrast aortogram using the brachial artery approach was performed, confirming complete thrombosis of the aortic endograft portion. A right axillary to bi-femoral artery bypass graft was performed, successfully restoring blood flow to both lower extremities. The post-operative period was complicated by an incisional wound infection at the left groin, successfully treated with debridement and sartorius muscle flap. The patient was discharged home on post-operative day 30. He was counseled regarding the importance of surveillance of the bypass and aortic endografts. Unfortunately, the patient was dissatisfied and was lost to follow-up.
Two years later, the patient returned to the emergency room with sudden and severe abdominal pain. Vital signs showed the patient to be hypotensive and tachycardic. Lab results demonstrated a low hemoglobin and elevated creatinine. A CT without contrast was performed (Figure 1), showing rupture of the previously thrombosed AAA with extravasation of blood into the retroperitoneum. The patient was taken emergently to the operating room, where an exploratory laparotomy was performed. Supraceliac control was obtained and the aortic sac was entered. A type 1A endoleak was found at the proximal stent graft. The proximal portion of the graft was excised and the infra-renal aorta was suture ligated and oversewn. Despite the massive transfusions, the patient became coagulopathic. The procedure was completed, and the abdomen was closed to quickly transfer to the intensive care unit for resuscitation. However, at the conclusion of the procedure, the patent went into cardiac arrest and despite attempts at cardio-pulmonary resuscitation, expired on the operating table.
Non-contrast CT of abdomen and pelvis showing a large amount of free intraperitoneal blood from the ruptured AAA.
Discussion
EVAR has become the first choice in AAA repair in high-risk patients with suitable anatomy.1,2 EVAR can be performed with considerably lower short-term risks compared to open repair, however, long-term outcomes when have been similar.1,3–5 Additionally, EVAR has also been associated with an increased risk of late rupture compared with open AAA repairs.1,6–8 As a result, EVAR patients have been shown to require more secondary interventions, demonstrating the necessity of long-term follow-up.4,9
The occurrence of a completely thrombosed endograft is a rare complication. At present, there are multiple multicenter prospective randomized control trials such as the EUROSTAR, DREAM, and OVER trials which compared open and endovascular AAA patients.1,3,7 These trials have the addressed the advantages and disadvantages of endovascular versus open repair for short-term and long-term morbidity and mortality rates. In the EUROSTAR trial, the most common type of endoleak resulting in a rupture was type I and III endoleaks. 7 Complete graft thrombosis of the aortic limb was not seen in any of the multicenter studies. In contrast, thrombosis of the iliac limbs occurred in up to 17% and was most commonly unilateral. 3
To our knowledge, no studies have explicitly addressed the need for surveillance, or the complications of thrombosed aortic endografts. With our current experience in mind, we propose that all patients with complete thrombosis of the aortic limb of an aortic endograft receive continued graft surveillance, which can be performed by CT angiogram, or ultrasound duplex. With the appropriate surveillance, the development of an endoleak, or an enlarging aortic sac can be diagnosed and repaired prior to rupture. This report highlights the importance of continued surveillance of the aortic sac even after total thrombosis of the EVAR.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Statement of consent
Consent for this case report was not able to be obtained from the patient as he is deceased. Multiple attempts at contacting any living relatives were made, however unsuccessful. It is likely that their address and phone number on file from the last visit have been changed. As such, all identifying markers and clues from the case report have been omitted in order to maintain complete anonymity.