Ruptured abdominal aortic aneurysm after endovascular aortic aneurysm repair.
ABSTRACT In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been employed 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.
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ABSTRACT: ZusammenfassungEndoleaks vom Typ II treten nach endovaskulärer Ausschaltung eines infrarenalen Aortenaneurysmas (EVAR) mit einer Häufigkeit von bis zu 20 % auf und können sehr selten zur Aneurysmaruptur führen. Therapeutische Konsequenzen des Typ-IIEndoleaks reichen wegen seiner langfristig unklaren prognostischen Relevanz von der konservativen Therapie bis zur Konversion. Methoden: In Form einer Kasuistik wird ein weiterer Fall einer Aneurysmaruptur nach EVAR durch ein Typ-II-Endoleak beschrieben. Anhand einer Literaturanalyse wird eine Behandlungsstrategie dafür entwickelt. Ergebnisse: Eine 62-jährige Patientin wurde mit einer gedeckten Ruptur 40 Monate nach EVAR mit einem aortobiiliakalen Stentprothesensystem (Talent, World Medical) aufgenommen. Die Patientin hatte bei bekanntem Typ-II-Endoleak während der letzten zwei Jahre keine Follow-up-Untersuchung mehr wahrgenommen. Nach sofortiger Laparotomie fanden sich blutende Lumbalarterien und die A. mesenterica inferior als Ursache eines Typ-II-Endoleaks und damit der Aneurysmaruptur. Nach Explantation des Stentprothesensystems und konventionellem aortobiiliakalem Protheseninterponat ergab eine MRAKontrolle jedoch eine Dissektion der thorakalen und suprarenalen Aorta mit Minderperfusion der linken Niere. Die Patientin verstarb 44 Monate nach der Konversion an einem metastasierenden Ovarialkarzinom. Aus den Literaturdaten ergibt sich eine therapeutische Konsequenz bei großem (Nidus> 15 mm) oder persistierendem (> 6 Monate) Typ-II-Endoleak und bei Größenprogredienz des Aneurysmasackes. Diskussion: Die rechtzeitige selektive Therapie des Typ-II-Endoleaks ist zur Prophylaxe der Aneurysmaruptur nach EVAR indiziert. Bei Ruptur durch ein Typ-II-Endoleak kann alternativ zur Konversion die Nahtligatur der blutenden Arterien mit Verschluss des Aneurysmasackes und Belassen der Stentprothese erwogen werden. SummaryType II endoleaks occur in up to 20 % of patients after endovascular aortic aneurysm repair (EVAR) and may rarely cause aneurysm rupture. Because of controversial long-term prognosis there is a variety of therapeutic options ranging from conservative treatment to conversion. Methods: Another case history is presented of infrarenal aortic aneurysm rupture caused by type II endoleaks after EVAR. Based on a literature review, a treatment strategy is proposed. Results: A 62-year-old woman was admitted with contained rupture 40 months after previous EVAR with an aortobiiliac stent-graft system (Talent, World Medical). The patient had been lost to follow-up for the last two years. Immediate laparotomy was performed. The intraoperative findings revealed lumbar arteries and the inferior mesenteric artery bleeding into the aneurysm sac, thus confirming the diagnosis of type II endoleaks. However, after explantation of the stent-graft system and conventional aortobiiliac repair MRA showed a dissection of the thoracic and suprarenal aorta with impairment of left kidney perfusion. The patient died 44 months later of a spreading ovarial carcinoma. The literature analysis revealed that therapeutic consequences are indicated with large (nidus > 15 mm) or persistent (> 6 months) type II endoleaks and with growing aneurysm sac. Discussion: Aneurysm rupture can be prevented by selective and timely therapy of type II endoleaks. In case of aneurysm rupture after EVAR due to type II endoleaks oversewing of the bleeding arteries and tight closure of the aneurysm sac, thereby maintaining the stent-graft in place, should be considered as a treatment option.12/2010: pages 77-84;
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ABSTRACT: It has been proposed that prior endovascular abdominal aortic aneurysm (AAA) repair (EVAR) confers protective effects in the setting of ruptured AAA (rAAA). This study was conducted to compare outcomes of rAAA repairs in patients with and without prior EVAR. A retrospective review identified 18 patients with (group 1) and 233 patients without (group 2) antecedent EVAR who presented with rAAA from January 2001 to December 2008. Patient characteristics and perioperative variables were noted and the outcomes were compared. Multiple logistic regression was used to identify factors contributing to morbidity and mortality and Kaplan-Meier analyses to estimate late survival rates. Baseline characteristics were similar between groups. Mean age was 78 years in group 1 and 74.8 years in group 2 (P=.17). Men comprised 83.3% of patients in group 1 and 77.3% in group 2 (P=.77). Hemodynamic instability at rAAA was noted with similar frequency between groups, 55.6% vs 52.6%, respectively (P=.99). Mean time from EVAR to rAAA was 4.0 years and from last follow-up computed tomography (CT) 1.2 years. The devices involved were Ancure (Guidant, Menlo Park, Calif) (9), AneuRx (Medtronic, Minneapolis, Minn) (5), Zenith (Cook Medical Inc, Bloomington, Ind) (3), and Excluder (W.L Gore, Flagstaff, Ariz) (1). Mean preoperative AAA size was 6.4 cm in group 1. All but 1 patient had an endoleak at the time of rupture. Of 14 patients with CT follow-up, only 3 patients had a known increase in size (≥5 mm) and only 3 were known to have an endoleak. Fifteen patients were treated by a single intervention, whereas 3 patients underwent multiple procedures. In group 2, open repair was performed in 218 patients and EVAR in 15. Morbidity (66.7% vs 56.7%) and in-hospital mortality (38.9% vs 36.9%) were nearly identical between groups. One-year survival rates (27.8% vs 48.2%; P=.15) were also similar. The mortality rates for EVAR for primary rAAA was 20% as compared to 38.1% for open repair for rAAAs (P=.27). rAAA remains a lethal problem in patients with and without prior EVAR alike. An existing endograft provides neither acute nor 1-year survival benefits after rAAA repairs. Prediction of patients at risk for rupture post-EVAR is difficult, as only a minority of patients had a known prior endoleak or sac enlargement.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 11/2010; 52(5):1127-34. · 3.52 Impact Factor
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ABSTRACT: The purpose of this study was to determine the long-term results of a 7-year follow-up of endovascular aneurysm repairs (EVARs) of abdominal aortic aneurysms (AAAs) using custom-made stent grafts (SGs). We performed a retrospective review of 17 patients (14 males, 3 females; mean age: 74.3 +/- 7.9 years; range: 53-85) undergoing EVAR of infrarenal aortic aneurysms at our institution from April 2000 to August 2006. The primary and secondary clinical success rates were 82.4% (14/17) and 100% (17/17). The initial and short-term clinical success rates were 100%. During follow-up (mean: 38.8 +/- 35.9 months; range: 0.8-90 months), 4 patients died, but there was no aneurysm-related death. In 2 patients, additional surgery was performed. The long-term clinical success rate was 83.3% (5/6). In the Kaplan-Meier curve, the 1- and 5-year survival rates were 55.0% and 45.8%, respectively. The initial and short-term clinical success rates were 100%; regarding the short-term, aneurysm-related death could be avoided. However, during long-term follow-up, aneurysm-related events did occur. Follow-up should be performed over a long period.Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 08/2010; 16(1):26-30.
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
− 69 −
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
− 71 −
1. Parodi JC, Palmaz JC, Barone HD. Transfemoral intra-
luminal graft interposition for abdominal aortic aneurysm.
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nal aortic aneurysm endografting: 7-year concurrent com-
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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.
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pair after endogrfting for abdominal aortic aneurysm: cause,
incidence and results. Eur J Vasc Endovasc Surg 2006;31:
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