VASCULAR IMAGES
Hybrid repair of ruptured thoracoabdominal aortic aneurysm in a patient with previous endovascular abdominal aortic aneurysm repair and thoracic endovascular aneurysm repair Faisal Aziz, MD, FACS, Hershey, Pa A 61-year-old man presented to the emergency department with acute onset of severe abdominal and back pain. His surgical history was significant for thoracic endovascular aneurysm repair (TEVAR) 15 months earlier with a 34-mm endograft at another institution. Six months later, he had undergone elective endovascular abdominal aortic aneurysm repair (EVAR) with 28-mm bifurcated device. On physical examination, he was hypotensive and had a distended and firm abdomen. Computed tomography angiography of the chest, abdomen, and pelvis showed a rupture of the aneurysmal aortic segment between the previously placed TEVAR stent graft and EVAR stent grafts (A/Cover, B, and C). A type IB endoleak was also seen in the right iliac extension (B and C). The patient was brought emergently to the operating room. The aneurysmal segment was covered with a 32-mm straight endograft inferiorly and a 38-mm straight endograft superiorly. This covered the origins of celiac, superior mesenteric, and bilateral renal arteries. An exploratory laparotomy was performed, and right external iliac arteryto-superior mesenteric artery bypass was performed with an 8-mm polytetrafluoroethylene graft. Owing to the patient’s hemodynamic instability and long operative time, the renal arteries were not revascularized. Postoperatively, the patient required dialysis. He did not have any sensory or motor loss in either extremity. The patient was discharged after a prolonged hospital stay of 5 weeks. DISCUSSION The risk of aortic rupture after EVAR is 2.4% within 8 years after repair.1 The lifetime risk of rupture is even higher, because most patients live a long time after the procedure.2 The mean interval between the initial procedure and subsequent abdominal aortic aneurysm rupture is 24 months.3 Endoleaks are identified as the main cause of rupture.3 This case is unique, because it is rare for a rupture of the aortic segment to occur between thoracic and aortic stents. REFERENCES 1. Leurs LJ, Buth J, Laheij RJ. Long-term results of endovascular abdominal aortic aneurysm treatment with the first generation of commercially available stent grafts. Arch Surg 2007;142:33-41; discussion: 42. 2. Schermerhorn ML, Finlayson SR, Fillinger MF, Buth J, van Marrewijk C, Cronenwett JL. Life expectancy after endovascular versus open abdominal aortic aneurysm repair: results of a decision analysis model on the basis of data from EUROSTAR. J Vasc Surg 2002;36:1112-20. 3. Schlosser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, et al. Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur J Vasc Endovasc Surg 2009;37:15-22. Submitted Jul 3, 2013; accepted Jul 8, 2013.
From the Section of Vascular Surgery, Department of Surgery, Heart & Vascular Institute, Pennsylvania State University College of Medicine. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;59:524 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.07.004
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Hybrid repair of ruptured thoracoabdominal aortic aneurysm in a patient with previous endovascular abdominal aortic aneurysm repair and thoracic endovascular aneurysm repair Faisal Aziz, MD, FACS, Hershey, Pa A 61-year-old man presented to the emergency department with acute onset of severe abdominal and back pain. His surgical history was significant for thoracic endovascular aneurysm repair (TEVAR) 15 months earlier with a 34-mm endograft at another institution. Six months later, he had undergone elective endovascular abdominal aortic aneurysm repair (EVAR) with 28-mm bifurcated device. On physical examination, he was hypotensive and had a distended and firm abdomen. Computed tomography angiography of the chest, abdomen, and pelvis showed a rupture of the aneurysmal aortic segment between the previously placed TEVAR stent graft and EVAR stent grafts (A/Cover, B, and C). A type IB endoleak was also seen in the right iliac extension (B and C). The patient was brought emergently to the operating room. The aneurysmal segment was covered with a 32-mm straight endograft inferiorly and a 38-mm straight endograft superiorly. This covered the origins of celiac, superior mesenteric, and bilateral renal arteries. An exploratory laparotomy was performed, and right external iliac arteryto-superior mesenteric artery bypass was performed with an 8-mm polytetrafluoroethylene graft. Owing to the patient’s hemodynamic instability and long operative time, the renal arteries were not revascularized. Postoperatively, the patient required dialysis. He did not have any sensory or motor loss in either extremity. The patient was discharged after a prolonged hospital stay of 5 weeks. DISCUSSION The risk of aortic rupture after EVAR is 2.4% within 8 years after repair.1 The lifetime risk of rupture is even higher, because most patients live a long time after the procedure.2 The mean interval between the initial procedure and subsequent abdominal aortic aneurysm rupture is 24 months.3 Endoleaks are identified as the main cause of rupture.3 This case is unique, because it is rare for a rupture of the aortic segment to occur between thoracic and aortic stents. REFERENCES 1. Leurs LJ, Buth J, Laheij RJ. Long-term results of endovascular abdominal aortic aneurysm treatment with the first generation of commercially available stent grafts. Arch Surg 2007;142:33-41; discussion: 42. 2. Schermerhorn ML, Finlayson SR, Fillinger MF, Buth J, van Marrewijk C, Cronenwett JL. Life expectancy after endovascular versus open abdominal aortic aneurysm repair: results of a decision analysis model on the basis of data from EUROSTAR. J Vasc Surg 2002;36:1112-20. 3. Schlosser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, et al. Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur J Vasc Endovasc Surg 2009;37:15-22. Submitted Jul 3, 2013; accepted Jul 8, 2013.
From the Section of Vascular Surgery, Department of Surgery, Heart & Vascular Institute, Pennsylvania State University College of Medicine. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;59:524 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.07.004
524
