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VASCULAR IMAGES
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Hybrid repair of ruptured thoracoabdominal aorticaneurysm in a patient with previous endovascularabdominal aortic aneurysm repair and thoracicendovascular aneurysm repairFaisal 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 endovascularaneurysm repair (TEVAR) 15months earlier with a 34-mm endograft at another institu-tion. Sixmonths later, hehadundergoneelectiveendovascular abdominal aortic aneurysmrepair (EVAR) with 28-mm bifurcated device.On physical examination, hewas hypotensive and had a distended and firm abdomen.Computed tomography angiography of the chest, abdomen, and pelvis showed a ruptureof the aneurysmal aortic segment between the previously placed TEVAR stent graft andEVAR stent grafts (A/Cover,B, andC). A type IB endoleakwas also seen in the right iliacextension (B and C).
The patient was brought emergently to the operating room. The aneurysmalsegment was covered with a 32-mm straight endograft inferiorly and a 38-mm straightendograft superiorly. This covered the origins of celiac, superiormesenteric, and bilateralrenal arteries. An exploratory laparotomy was performed, and right external iliac artery-to-superior mesenteric artery bypass was performed with an 8-mm polytetrafluoroethy-lene graft. Owing to the patient’s hemodynamic instability and long operative time, therenal arteries were not revascularized.
Postoperatively, the patient required dialysis. He did not have any sensory ormotor loss in either extremity. The patient was discharged after a prolonged hospitalstay of 5 weeks.
DISCUSSION
The risk of aortic rupture after EVAR is 2.4% within 8 years after repair.1 The lifetimerisk 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 aneu-rysm rupture is 24 months.3 Endoleaks are identified as the main cause of rupture.3 Thiscase is unique, because it is rare for a rupture of the aortic segment to occur betweenthoracic and aortic stents.
REFERENCES
1. Leurs LJ, Buth J, Laheij RJ. Long-term results of endovascular abdominal aortic aneurysm treatment withthe 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 expectancyafter endovascular versus open abdominal aortic aneurysm repair: results of a decision analysis model on thebasis 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.
the Section of Vascular Surgery, Department of Surgery, Heart & Vascular Institute, Pennsylvania Stateniversity College of Medicine.or conflict of interest: none.ail: [email protected] and reviewers of this article have no relevant financial relationships to disclose per the JVS policy thatquires reviewers to decline review of any manuscript for which they may have a conflict of interest.sc Surg 2014;59:524-5214/$36.00yright � 2014 by the Society for Vascular Surgery.://dx.doi.org/10.1016/j.jvs.2013.07.004
