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: To evaluate frequency, causes and results of conversion to Open repair (OR) after endovascular repair (EVAR) in a single centre during an 8-year period. Six hundred and forty-nine consecutive patients undergoing EVAR were followed up prospectively for endograft-related complications. Early conversion was any OR during or within 30 days from the primary EVAR. Late conversion was any OR with removal of the endograft after 30 days since a completed EVAR procedure. Median patient follow-up was 38 months (1-93 months). Conversion to OR was performed in 38 patients; nine early and 29 late. Most (7/9) early conversions were due to extensive vessel calcification. Peri-operative mortality was 22% (2/9). Late conversions occurred at a median of 33 months after primary EVAR: 29 were elective and 4 urgent. During the same interval, 79 secondary endovascular interventions were performed, 7 of which failed. The risk of conversion to OR was 9% at 6 years. At multivariate logistic regression analysis, no single factor (short, large or angulated neck, suprarenal fixation, large pre-operative diameter, iliac aneurysms, ASA score risk) was associated with the risk of late failure requiring conversion to OR. The risk of death after early conversion should be recognized, to avoid forcing morphological indications for primary EVAR. Occurrence of late conversion after EVAR is not negligible, affecting almost 1 out of 10 patients after 6 years. In the presence of an expanding aneurysm after EVAR, especially after a failed secondary endovascular correction, an aggressive attitude in fit patients allows outcomes at similar to those of primary OR.European Journal of Vascular and Endovascular Surgery 03/2006; 31(2):136-42. · 2.82 Impact Factor
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ABSTRACT: The purpose of this study was to analyse the technical problems associated with conversion from endoluminal repair of abdominal aortic aneurysms (AAA) to open repair and document the outcome in patients with this clinical course. Between May 1992 and May 1996 endoluminal repair of AAA was undertaken in 113 patients. Forty-eight of these had medical co-morbidities which led to them being rejected for open repair at other medical centres. Conversion from endoluminal to open repair was required in 18 patients. Thirteen of these occurred at the original operation (primary conversion) and five occurred at a later operation (secondary conversion). Seven of the 18 patients undergoing conversion had serious medical co-morbidities. Three different methods of open repair were used. The technique selected was determined by the cause of failure leading to conversion. Standard open AAA repair was used in patients requiring conversion for access problems (n = 2) and balloon malfunction, where the device ended up entirely within the aneurysmal sac (n = 1). Modifications to the standard technique were required in patients in which the endograft was correctly positioned immediately below the renal arteries and/or where part of the endograft was within one or both common iliac arteries (n = 11). Supra-coeliac control was required for patients with aortic rupture (n = 1), renal arteries covered by the endograft (n = 2) and situations where the delivery catheter was trapped within the aorta above a twisted bifurcated graft (n = 1). The mean volume of contrast used was 225 ml and the mean operative time was 5.25 h in patients undergoing primary conversion. Conversion to open repair was achieved in all 18 patients. Renal impairment requiring dialysis occurred in three patients. There were three perioperative deaths, all of which were procedure-related (17%), and one late death. All four deaths occurred from among the group of seven patients with preoperative co-morbidities. Converting an endoluminal to an open AAA repair may require modifications to the standard open technique and result in a much higher than generally accepted morbidity and mortality rate. Patients rejected for open repair because of co-morbidities ran the same chance of requiring conversion as those without co-morbidities (15-17%). If conversion was required, however, they stood a 3 in 7 or 43% chance of dying.European Journal of Vascular and Endovascular Surgery 08/1997; 14(1):4-11. · 2.82 Impact Factor
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ABSTRACT: We compared the effectiveness and clinical outcome of open repair versus endovascular aortic aneurysm repair (EVAR) in achieving prevention of abdominal aortic aneurysm (AAA)-related death and graft-related complications. Over 7 years from 1997 to 2003, 1119 consecutive patients underwent elective treatment of infrarenal AAAs, 585 with open repair and 534 with EVAR. Patients were regularly followed up at 1, 6, 12 months, and every 6 months thereafter, in EVAR group, and at 3 and 12 months, and yearly thereafter after open repair. Preoperative, intraoperative, and follow-up data were stored in a prospective database. Median follow-up was similar in the 2 groups: 33 months (interquartile range [IQR], 13-50 months) in the EVAR group vs 35 months (IQR, 15-54 months) in the open repair group. EVAR group patients were older than patients in the open repair group: 73 years vs 72 years (P = .04). There were statistical significant differences between the EVAR group and the open repair group with respect to AAA median diameter (52 mm vs 56 mm), coronary disease rate (46% vs 37%; P = .001), pulmonary disease rate (56% vs 38%; P < .0001), and American Society of Anesthesiologists IV score rate (16% vs 6%; P < .0001). Thirty-day mortality in the EVAR group was 0.9% (5 of 534 patients), compared with 4.1% (24 of 585 patients; P = .001) in the open repair group, and major morbidity was 9.1% (49 of 534 patients) vs 18.6% (109 of 585 patients; P < .0001), respectively. The incidence of secondary procedures in the EVAR group was 15.7%, compared with 3% in the open repair group (P < .0001). There were no deaths related to secondary procedures in either group. Six AAAs (1.1%) ruptured after EVAR, 3 of which were fatal; in the open repair group 1 patient (0.2%) underwent successful repeat operatation to treat iliac pseudoaneurysm rupture 5 years after the original procedure. Kaplan-Meier estimates for freedom from aneurysm-related death at 84 months were 97.5% in the EVAR group and 95.9% in the open repair group (log rank test, P = .008). Kaplan-Meier survival estimates at 84 months were 67.1% in the open repair group and 66.9% in the EVAR group (P = NS). At the same interval the risk for secondary procedures was 49.4% for the EVAR group and 7.1% for the open repair group. Of the 11 variables analyzed with logistic analysis, open surgery (hazard ratio [HR], 11; 95% confidence interval [CI], 2.5-54.2; P = .002), American Society of Anesthesiologists IV score (HR, 7.1; 95% CI, 2.7-18.8; P = .0001), and age (HR, 1.06; 95% CI, 1.04-1.13; P = .04) were positive independent predictors of perioperative mortality. Our data suggest that at a maximum follow-up of 7 years, patients who undergo EVAR show lower perioperative and late aneurysm-related mortality compared with a younger and substantially healthier group of patients with aneurysms treated with open repair. The higher need for secondary procedures in the endovascular group did not affect superiority of the overall performance of EVAR in the early and late intervals.Journal of Vascular Surgery 11/2004; 40(5):841-8. · 2.88 Impact Factor
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-
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abdominal aortic aneurysm in the medicare population. N
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incidence and results. Eur J Vasc Endovasc Surg 2006;31:
5. Harris PL, Vallabhaneni SR, Desgranges P, Becquemin JP,
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