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Salvage EVAR Using A Bifurcated Aortic Endograft In A Case Of Aortic Endograft Stent Migration
Gerard P. De Castro, MD, MPH, Nikita Tihonov, MD, Chad E. Jacobs, MD, Ulku C. Turba, MD, Bulent Arslan, MD, Walter J. McCarthy, MD.
Rush University Medical Center, Chicago, IL, USA.
OBJECTIVE - We present a case of a re-operative EVAR in a 72 year old female with chronic renal failure who underwent an EVAR in 2004 and presented with abdominal and lower back pain. A CTA of her abdomen and pelvis demonstrated that her endograft had migrated distally and folded upon itself within the aneurysm sac (see Fig. 1a & b) while still maintaining flow through the stent graft and iliac limbs. The aneurysm sac was still fully pressurized and measured to be 6.8cm.
METHODS - We performed a re-operative EVAR through the previous aortic endograft via bilateral femoral artery incisions. A 36x16x145 Medtronic Endurant II modular bifurcated endograft with a 16x24x156 right limb extension and 16x16x156 and 16x16x124 left limb extensions was used. The main body graft was situated just distal to the celiac artery due to extension of her aneurysmal disease above the level of the renal arteries. The renal arteries were covered by the main body graft in this renal failure patient but the SMA was preserved with an 8x50 Viabahn stent and a 7x38 iCAST stent extension that was placed via snorkel technique by way of a left brachial artery access.
RESULTS - Completion arteriogram demonstrated successful aortic bifurcated endograft placement with widely patent iliac limbs. Both the celiac and SMA arteries were also widely patent. (Fig. 1c)
CONCLUSION - Stent graft migration is a known complication of EVAR. Treatment with unibody prostheses, proximal aortic extender cuffs, and open surgical conversion has been described. Re-operative EVAR using a bifurcated aortic endograft is another alternative in treating stent graft migration in carefully selected cases.
Fig. 1 (a, b, &c).
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