Rupture of an abdominal aortic aneurysm previously repaired with an endovascular stent-graft: successful management using an endovascular approach.

Abdominal Aortic Aneurysm Ruptured abdominal aortic aneurysm foll l lowing previous deployment of an endol l luminal graft is a relatively new vascular emergency. As more patients are treated by endovascular repair, more will present with postlEVAR acute AAA. This new challenging entity is raising the need for new treatment strategies. We describe a case of postlEVAR ruptured AAA that was managed successfully using the endovasl l cular approach. A 79 year old man presented to the emerl l gency department hemodynamically stable with a 4 hour history of severe abdominal and back pain. Six years previously he had undergone elective endovascular abdomil l nal aortic aneurysm repair with a modular bifurcated endoluminal graft. He was lost to followlup after 2 years, at which point he had no evidence of endoleak. Urgent computerized tomography angil l ography revealed a contained rupture of an 11 cm abdominal aortic aneurysm with an extensive retroperitoneal hematoma. A large endoleak was demonstrated and apl l peared to be related to the distal attachl l ment of the left limb of the stent graft, i.e., a Type Ib endoleak [Figure A]. Plain abdominal films failed to demonstrate any modular disconnection or stent fractures. The patient had significant colmorbidities, including severe cardiomyopathy, ischl l emic heart disease, chronic obstructive lung disease, and hypertension, making a minimally invasive treatment approach desirable. EVAR = endovascular abdominal aortic aneurysm repair AAA = abdominal aortic aneurysm In the operating room, under general anesthesia the left femoral artery was exposed and the previous stent graft cannulated with a pigtail catheter. Anl l giography confirmed a large type Ib enl l doleak [Figure B]. A 14 x 71 mm Zenith extension limb (W.A. Cook, Brisbane, Australia) was deployed over a stiff wire from inside the stent graft to the proxil l mal external iliac artery, covering the leak and the origin of the internal iliac artery. Completion angiography revealed no endoleaks and a good flow distally. The left internal iliac artery was then ligated via a retroperitoneal approach. Followlup CT angiography on the third postoperative day confirmed that the endoleak had been sealed successfully. On the fourth postoperative day the patient required a right hemicolectomy, end ileostomy, and tube transverse colostomy due to cecal ischemia secondary to colonic pseudolobstrucl l tion. The following day he developed severe hemorrhagic shock secondary to intraabdominal bleeding from the ileostomy site. Secondary thrombosis of the left …