Efrain Aguilar, Tuong Nguyen, Thaer Obaid, Rashad Choudry and Evan Deutsch
Introduction: Successful endovascular aortic aneurysm repair (EVAR) aims to prevent catastrophic rupture, however despite technical excellence at index operation, long term follow up remainsm and atory. This is due to the fact that delayed aortic rupture may occur in certain patients after EVAR. We present a technically challenging case which illustrates this concern.
Case report: An 82 year old man underwent successful EVAR using a redesigned, clinical trial graft (Medtronic, Minneapolis, MN), five years prior to presentation. He was lost to follow after the initial procedure. At presentation to us, he demonstrated a 13.5cm, ruptured infrarenal aortic aneurysm due to proximal aortic neck enlargement and endograft slippage. Emergency repair included a proximal supra-renal endograft extension (Endologix, Irvine, CA), femoralfemoral bypass (PTFE), and open abdomen with negative-pressure therapy (Abthera, KCI, San Antonio, TX) He survived and was discharged with close follow-up. He re-presented six months later with flank pain and a WBC 22,000. A CT Scan was concerning for a new contained aortic rupture (16cm) and a recurrent proximal endograft slip.
High clinical suspicion resulted in a return to operating room for axillary to femoralfemoral artery bypass (PTFE), followed by explantation of the endograft system, aortic sac resection, and omental flap coverage. Operative cultures yielded Staphylococcus epidermis. He survived again and was discharged on a plan for long term antibiotics on postoperative day 10.
Conclusion: Long term follow up after EVAR may help to identify patients at high risk for endo-graft failures. Aortic neck enlargement leading to rupture may result from primary aneurysm growth, however infection can be an important cause. Time honored open aortic surgical techniques remain an important tool for every vascular surgeon.
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