Endarterectomy of the Aneurysm Sac in Open Abdominal Aortic Aneurysm Repair Reduces Perigraft Seroma and Improves Graft Incorporation

The Potential Relation Between polytetrafluoroethylene Grafts after Open Reconstructions for Abdominal Aortic Aneurysm and Perigraft Seromas

BACKGROUND

The presence of sac enlargement after abdominal aortic aneurysm (AAA) open repair, a condition usually called perigraft seroma (PGS), nearly always has a benign behavior. Some theories implicated for PGS formation include coagulation abnormalities, fibroblast inhibition, low-grade infection, or improper graft handling.

METHODS

This is a retrospective study including patients treated for AAA in 2 academic vascular surgery departments from 2007 to 2014, where 1 center preferably used polytetrafluoroethylene (PTFE) grafts whereas the preference of other center was mostly Dacron graft. The definition of PGS was conceived as a fluid collection around the graft on CT scan imaging with a radiodensity ≤25 Hounsfield units, reaching at least 30 mm in diameter and beyond the third postoperative month. Analysis was performed between patients with and without PGS.

RESULTS

Seventy-eight patients met the inclusion criteria: 42 received Dacron and 36 PTFE grafts. Twenty-three (29.5%) patients accomplished the PGS diagnosis. Having a PTFE graft was the strongest factor for PGS formation on multivariate analysis. The medium seroma size was 42 mm (range, 30-90.6 mm) and the mean time from AAA repair to PGS detection was 26 months (range, 4-106 months). Three patients of the 23 with PGS required surgical repair, all of them were successfully treated: 2 by endovascular means and the remaining with explantation and Dacron reconstruction.

CONCLUSIONS

PGS formation is not an unusual complication after open reconstructions for AAA treatment. This is especially true for PTFE grafts, and thus, closer follow-up is warranted if using this material. Treatment is clearly needed when symptoms appear; however, preventive strategies with either endovascular relining or reopen reconstructions require an individual approach counterbalancing benefits versus risk of the procedures.

Perigraft seroma penetrating the aortic sac and rupturing into the intraperitoneal cavity

We present a case of a 66-year-old woman who developed perigraft seroma after having undergone elective, open abdominal aortic aneurysm repair with a polytetrafluoroethylene graft 5 years previously. One year after graft implantation, she started to suffer from abdominal discomfort and was therefore offered surgical intervention, which she declined owing to the fear of postoperative complications. Instead, an observational strategy was used. Five years later, the patient presented with sudden severe abdominal pain. Subsequent laparotomy revealed that the pseudomembrane lining the perigraft seroma had penetrated through the native aortic wall and into the intraperitoneal cavity, where it had ruptured. The patient was successfully treated by replacing the polytetrafluoroethylene graft with a polyethylene terephthalate (Dacron) graft.