Successful Endovascular Repair of Complex Ruptured Abdominal Aortic Aneurysm with Back-Table Surgeon-Modified Fenestrated Stent Graft
Ahmed K. Ghamraoui, DO, MS, Joseph J. Ricotta, II, MD, MS, FACS.
Delray Medical Center, Delray Beach, FL, USA.
DEMOGRAPHICS:
Despite advances in technology, ruptured abdominal aortic aneurysm (AAA) still carries a high risk of perioperative morbidity and mortality. While AAA is a typically asymptomatic condition not uncommonly seen in elderly men, it has the potential to be rapidly fatal; if left untreated, AAA rupture has a mortality rate of 100%. Even in patients who undergo intervention, ruptured AAA repair continues to carry a high rate of perioperative mortality, ranging from 20-60%. The most common risk factor for perioperative death is advanced age. Another major risk factor for perioperative morbidity and mortality is open repair. However, not all patients presenting with ruptured AAA are candidates for repair. Rupture of suprarenal AAA and free peritoneal rupture are typical exclusions to an endovascular approach. However, complex ruptured AAA may still be successfully treated endovascularly if a patient-customized fenestrated stent graft is immediately available for implantation. This can be possible through back-table surgeon modification of an off-the-shelf stent graft.
HISTORY:
An 86-year-old male presented to the emergency department with worsening back and groin pain and was found on imaging to have a pararenal abdominal aortic aneurysm with a contained rupture of the posterolateral wall. He had no previous knowledge of having an AAA.
PLAN:
The patient was taken to the endovascular operating room, where a Cook Zenith® stent graft was partially deployed and custom modified using specifications obtained from a three-dimensional reconstruction of the patient’s computed tomography angiogram (CTA) of the chest, abdomen and pelvis to create fenestrations for the superior mesenteric artery (SMA) and right and left renal arteries. This was deployed successfully without complication; the patient tolerated the procedure well and was kept overnight in the intensive care unit for close observation. His post-operative course remained unremarkable and he was discharged home on post-operative day three.
DISCUSSION:
Surgeon-modified fenestrated stent grafts allow a way to circumvent the high morbidity and mortality associated with open repair of complex ruptured abdominal aortic aneurysms, especially crucial in high-risk patients. Described above is a high-risk patient with a contained rupture of a complex abdominal aortic aneurysm, successfully treated with a back-table surgeon-modified three-vessel fenestrated stent graft with no perioperative morbidity.
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