Korean J Thorac Cardiovasc Surg 2011;44:68-71
□ Case Report □
ISSN: 2233-601X (Print) ISSN: 2093-6516 (Online)
− 68 −
*Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University
**Department of Radiology, School of Medicine, Pusan National University
†This work was supported for two years by Pusan National University Research Grant.
Received: August 4, 2010, Revised: September 15, 2010, Accepted: September 26, 2010
Corresponding author: Sung Woon Chung, Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University,
10, 1-ga, Ami-dong, Seo-gu, Busan 602-739, Korea
(Tel) 82-51-240-7263 (Fax) 82-51-243-9389 (E-mail) email@example.com
C The Korean Society for Thoracic and Cardiovascular Surgery. 2011. All right reserved.
CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative-
commons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Ruptured Abdominal Aortic Aneurysm after
Endovascular Aortic Aneurysm Repair
Chung Won Lee, M.D.*, Sung Woon Chung, M.D.*, Jong Won Kim, M.D.*,
Sangpil Kim, M.D.*, Mi Ju Bae, M.D.*, Chang Won Kim, M.D.**
In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been em-
ployed as a good alternative to open repair with low perioperative morbidity and mortality. However, the aneurysm
can enlarge or rupture even after EVAR as a result of device failure, endoleak, or graft migration. We experienced
two cases of aneurismal rupture after EVAR, which were successfully treated by surgical extra-anatomic bypass.
Key words: 1. Aneurysm
2. Aorta, abdominal
4. Endovascular surgery
1) Case 1
A sixty-six-year-old male patient visited the emergency
room with severe abdominal pain and distension. The patient
had received endovascular aortic aneurysm repair (EVAR) us-
ing bifurcated stent graft (S&G Biotech inc., Seongman,
Korea), about five years before. The patient had a history of
the second endovascular intervention for endoleak due to the
separation of the left iliac limb one year after EVAR (Fig.
1A, B). On arrival at the emergency room, his blood pressure
was 70/40 mmHg. As the abdominal computed tomography
(CT) showed an enlarged abdominal aortic aneurysm with ret-
roperitoneal hematoma (Fig. 1C), an emergency operation was
performed. Through median laparotomy the abdominal aorta
was dissected, but surgical exposure was difficult because of
the massive hematoma. After Supra-celiac aortic clamping
was done, removal of the implanted stent graft was
attempted. However, the proximal bare part of the stent,
which was firmly incorporated into the aortic wall by neo-
intimalization, could not be retrieved. Because bleeding from
the aorta was so severe on the attempt for stent retrieval and
bowl ischemia was suspected due to supraceliac clamping of
the aorta, extra-anatomic bypass grafting was contemplated as
a salvage procedure. After the stent was cut inside the aorta,
infrarenal portion of the aorta were oversewn and supraceliac
aortic clamp was released for bowl reperfusion. Two prox-
imal portions of the common iliac arteries were also over-
sewn, and left axillo-femoral and femorofemoral bypass was
performed using a ring reinforced 8mm polytetrafluoro-
ethylene (PTFE) grafts (Gore-Tex, USA). After adequate cir-
culation to the both feet was checked, he was transferred to
Ruptured Abdominal Aortic Aneurysm after Endovascular Aortic Aneurysm Repair
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Fig. 1. Case 1: (A) Contrast extra-
vasation of the left limb of stent
graft (Type III endoleak). (B) A co-
mpletion angiogram after additional
stent graft deployment. (C) Abdomi-
nal CT showing the enlarged abdo-
minal aortic aneurysm and retroperi-
toneal hematoma. (D) CT angiog-
raphy showing patent axillo-bifemoral
bypass graft one month after the
operation. CT=Computerized tomogr-
Fig. 2. Case 2: (A) An angiogram after endovascular aortic aneurysm repair. (B) Abdominal CT showing the ruptured abdominal aortic
aneurysm after EVAR. (C) CT angiography showing patent axillo-bifemoral bypass graft one month after the operation. CT=Computerized
tomography; EVAR=Endovascular aortic aneurysm repair.
the intensive care unit (ICU) in a critical condition. During
the postoperative course, he developed acute renal failure and
continuous renal replacement therapy was performed. He
stayed at the ICU for eight days, and he could be discharged
without any further complications at postoperative day 41.
The graft patency is has been well maintained for 24 months
of follow-up (Fig. 1D).
2) Case 2
A seventy-three-year-old male patient presented with severe
Chung Won Lee, et al
− 70 −
abdominal pain and hypotension. He underwent EVAR about
four years ago using a straight stent graft (S&G Biotech inc.,
Seongman, Korea) (Fig. 2A). He had histories of hyper-
tension and coronary artery disease. Because his blood pres-
sure was 60/40 mmHg and abdominal CT showed ruptured
abdominal aortic aneurysm (Fig. 2B), an emergency operation
was performed. When he arrived in the operating room, his
systolic blood pressure was checked at 40 mmHg. To main-
tain the cerebral and systemic perfusion, cardiopulmonary by-
pass was used commenced by cannulating the right femoral
vein and the right axillary artery. After median laparotomy
incision was made under the cardiopulmonary bypass, the
aorta was dissected and clamped below the renal arteries.
Because the stent graft could not be completely removed and
collapsed remnant of the stent graft hindered the inflow anas-
tomosis to a prosthetic graft, the infrarenal aorta and open-
ings of both common iliac arteries were oversewn for ex-
tra-anatomic bypass grafting. After cardiopulmonary bypass
was discontinued and laparotomy wound was closed, axil-
lo-bifemoral bypass was performed using a ring reinforced
8mm PTFE graft (Gore-Tex, USA). He was transferred to the
intensive care unit in a critical condition. He was supported
by a mechanical ventilator for 12 days and transferred to the
general ward in a stable state at postoperative day 15. CT an-
giography checked one month after the surgery showed good
flow through the bypass graft (Fig. 2C).
Since the first report of endovascular aortic aneurysm re-
pair (EVAR) by Parodi in 1991 , EVAR has been replac-
ing the open repair in most of the patients with favorable
anatomic features because of lower perioperative morbidity
and mortality than the latter [2,3].
However, the complications of EVAR such as device fail-
ure, endoleak, and graft migration may require a conversion
to open repair or lead to aneurysm enlargement or rupture.
Verzini et al.  reported that 4.5% patients required open
repair during a median follow-up of 38 months. Harris et al.
 reported an annual cumulative risk of 2.1% for conversion
to open repair in the EUROSTAR registry.
Furthermore, open surgical repair after EVAR usually turns
out to be more risky than the primary open repair. In the lit-
eratures, the mortality rates were reported to be as high as
20% [5,6]. The authors speculated that high mortality and
morbidity may be related to the presence of the endograft
which makes dissection difficult, and the need for suprarenal
or supraceliac aortic cross clamping.
We performed axillo-bifemoral bypass in two cases. This
procedure is much easier to perform than abdominal aortic
surgery, and can be applied to patients with risk factors such
as severe heart disease, chronic renal failure, severe pulmo-
nary dysfunction, and severe obesity. In our cases, one pa-
tient showed left kidney atrophy on preoperative CT, and the
other patient had a history of coronary artery disease. We
think that the extra-anatomic bypass alleviated the risk of
postoperative morbidity and mortality thanks to the shortening
of aortic cross clamping time. Because the collapsed stent
graft made it difficult to perform proximal inflow anasto-
mosis, extra-anatomic bypass was thought to be a safer op-
tion than time-consuming conventional aortoiliac graft
interposition. Long-term patency of the axillofemoral grafts,
however, is to be closely followed up.
Halpern et al.  reported that loss of consciousness is a
preceding sign of mortality in patients with ruptured abdomi-
nal aortic aneurysm (AAA). When AAA ruptures, an in-
dependent risk factor associated with immediate mortality is
the hemodynamic instability of the patients . Because pre-
operative vital signs of our second patient were very unstable,
we decided to use cardiopulmonary bypass (CPB) to maintain
the cerebral perfusion and systemic circulation. The employ-
ment of CPB might be helpful as a life-saving measure for
the patient who shows ruptured AAA with unstable vital
In conclusion, we could successfully treat the patients with
EVAR-related AAA rupture by extra-anatomic bypass graft-
ing, with or without the aid of cardiopulmonary bypass. We
think that the options for post-EVAR aneurysm rupture
should include a conversion to extra-anatomic bypass, be-
cause performing a salvage procedure is safer than sticking to
anatomic repair. Using CPB also could be helpful in case of
critically ill patients with ruptured AAA.
Ruptured Abdominal Aortic Aneurysm after Endovascular Aortic Aneurysm Repair
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1. Parodi JC, Palmaz JC, Barone HD. Transfemoral intra-
luminal graft interposition for abdominal aortic aneurysm.
Ann Vasc Surg 1991;5:491-9.
2. Cao P, Verzini F, Parlani G, et al. Clinical effect of abdomi-
nal aortic aneurysm endografting: 7-year concurrent com-
parison with open repair. J Vasc Surg 2004;40:841-8.
3. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P,
Pomposelli F, Landon BE. Endovascular vs. open repair of
abdominal aortic aneurysm in the medicare population. N
Engl J Med 2008;358:464-74.
4. Verzini F, Cao P, De Rango P, et al. Conversion to open re-
pair after endogrfting for abdominal aortic aneurysm: cause,
incidence and results. Eur J Vasc Endovasc Surg 2006;31:
5. Harris PL, Vallabhaneni SR, Desgranges P, Becquemin JP,
van Marrewijk C, Laheij RJ. Incidence and risk factors of
late rupture, conversion, and death after endovascular repair
of infrarenal aortic aneurysms: the EUROSTAR experience. J
Vasc Surg 2000;32:739-49.
6. May J, White GH, Yu W, et al. Conversion from endolumi-
nal to open repair of abdominal aortic aneurysm. A hazard-
ous procedure. Eur J Vasc Endovasc Surg 1997;14:4-11.
7. Halpern VJ, Kline RG, D’Angelo AJ, Cohen JR. Factors
that affect the survival rate of patients with ruptured ab-
dominal aortic aneurysms. J Vasc Surg 1997;26:939-48.
8. Coppi G, Silingardi R, Gennai S, Saitta G, Ciardullo AV. A
single-center experience in open and endovascular treatment
of hemodynamically unstable and stable patients with rup-
tured abdominal aortic aneurysms. J Vasc Surg 2006;44: