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INTRODUCTION: Successful endovascular aortic aneurysm repair (EVAR) aims to prevent catastrophic rupture. Despite technical excellence at the index operation, long-term follow-up remains mandatory to continually assess for any changes that may lead to a delayed aortic rupture. We present a technically challenging case which illustrates this concern.
CASE REPORT: An 82-year-old man presented to our institution with back pain. Computed tomography showed a 13.5cm ruptured infrarenal aortic aneurysm due to proximal aortic neck enlargement and endograft migration. Five years prior to this event, he had undergone successful EVAR using a redesigned, clinical trial graft (Medtronic, Minneapolis, MN). Unfortunately, he was lost to follow-up after the initial procedure. Emergency repair included a proximal supra-renal endograft extension (Endologix, Irvine, CA), femoral-femoral bypass (PTFE), and open abdomen with negative-pressure therapy (Abthera, KCI, San Antonio, TX). He survived and was discharged with close follow-up including serial imaging. Eleven months later, the patient presented with flank pain and a WBC 22,000. Computed tomography showed a new contained 16cm aortic rupture and a recurrent proximal endograft migration. He was taken to the operating room for axillary to femoral-femoral 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 long-term antibiotics.
CONCLUSION: This case highlights the continued need for routine follow-up after EVAR to identify patients with endograft failures. Rupture from aortic neck enlargement leading to endograft migration and aneurysm sac growth is certainly a recognized phenomenon. Additionally, infection can also be a contributing factor. Finally, despite the continuing improvement in EVAR technology, time-honored open aortic surgical techniques still remain an important tool for every vascular surgeon.