Deterioration of proximal anastomosis three decades after open aneurysmorrhaphy with endovascular salvage
Jason Hwang, James Cutcliffe, Stephen Lalka.
Conemaugh Memorial Medical Center, Johnstown, PA, USA.
Objectives - Symptomatic aneurysmal sac enlargement is a rare but documented complication of open abdominal aortic aneurysm (AAA) repair. Reported cases show that it usually develops in relation to breakdown of the proximal anastomosis several months to years after initial repair.
Methods - This is a case report of a 93-year-old male presenting with breakdown of the proximal anastomosis of a tube graft repair of his AAA performed 30 years previously, with leak into, and progressive expansion of the aneurysm sac that had been closed around the graft. This patient had B-cell lymphoma in remission and thus had had serial computed tomographic (CT) scans. His last CT, two years previous, showed a stable 41 x 37 mm AAA sac.
Results - He presented with a bleeding duodenal ulcer at the junction of the second and third portions, biopsied as lymphoma. CT showed a 95 x 85 mm AAA sac with endoleak from the proximal anastomosis of the tube graft. Preoperative white blood cell scan was negative for aortic graft infection. While in the hospital for preoperative evaluation, he developed back pain. Repeat CT showed increase of the AAA sac to 191 x 87 mm with over 1.5-fold expansion of the endoleak volume and marked increase in the Hounsfield unit intensity of the endoleak to near-equivalence with the intraluminal aorta. He was brought emergently for repair using a modular bifurcated endograft with coverage of the lowermost renal artery to obtain adequate native aortic apposition of the stent graft. There was no post-deployment endoleaks. The patient was discharged in satisfactory condition on postoperative day three.
Conclusions - Deterioration of the anastomosis of an open AAA repair with subsequent endoleak into the residual aneurysm sac is a rare but potentially lethal late complication. We demonstrate that this can be successfully treated using endovascular techniques. 
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