Ruptured Abdominal Aortic Aneurysm after Endovascular Aortic Aneurysm Repair

Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University, Korea.
Korean Journal of Thoracic and Cardiovascular Surgery 02/2011; 44(1):68-71. DOI: 10.5090/kjtcs.2011.44.1.68
Source: PubMed


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. © The Korean Society for Thoracic and Cardiovascular Surgery. 2011.

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    ABSTRACT: The goal of endovascular aortic aneurysm repair (EVAR) is to prevent continued AAA expansion and ultimate rupture by excluding the aneurysm from the arterial circulation. By this means, sys- temic arterial pressurization of the sac is elimi- nated and rupture risk eliminated. In the nearly two decades of experience with EVAR, failure to completely exclude the AAA from arterial flow (endoleak) has been observed in 15-25% or more of patients, and represents a common cause of late failures of this method- ology. While consensus exists that types I and III endoleaks are high-pressure and demand re-intervention and correction, uncertainty and controversy persist regarding the outcome and clinical significance of retrograde branch (type II) endoleaks. Although there has been growing recognition that type II endoleaks may be safely observed in many cases without re-intervention, our experience and that of others reported in the literature demonstrates that type II endoleaks are not always benign; indeed analysis documents that persistent type II endoleaks > 12 months are clearly associated with increased risk of adverse late outcomes including continued aneurysm growth, higher rates of reintervention and need for open conversion, and even late AAA rupture. Because of the possibility of endoleak or other graft-related problems, there is general agree- ment that ongoing imaging surveillance is neces- sary. Contrast-enhanced CT scan has long been the mainstay for follow-up, but growing concern regarding its cost, potential adverse impact on long-term renal function, and increasing radia- tion exposure have led many to investigate other modalities EVAR surveillance. However, at present little data exists to support the accuracy and effectiveness of alternative methods. All forms of imaging have in common the fact that they provide only indirect surrogates for evaluating the ultimate goal of EVAR: de- pressurization of the AAA sac. In contrast, the ability to directly measure intrasac pressures would enable one to document effective exclu- sion following EVAR. More importantly, direct
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