Endovascular repair of a saccular infrarenal aortic aneurysm in a liver transplant patient

Endovascular stenting as treatment for occult perforated abdominal aorta caused by acute necrotizing pancreatitis as rare complication after heart transplantation

With an increase in the population of living cardiac allograft recipients, noncardiac surgery in this group of patients will be a more frequent phenomenon. The postoperative management in these patients is, however, complex. The authors present a case of an abdominal aortic rupture due to the involvement of a necrotizing pancreatitis caused by the side effects of immunosuppressive therapy. A 48-year-old man presented with a necrotizing pancreatitis with accidental affection of the abdominal aortic wall, necessitating emergency repair. Open surgical repair was considered too precarious in a cardiac allograft recipient, aortic stent-graft through endovascular surgery was therefore opted as the preferred procedure. The subsequent postoperative course was uneventful and patient could be discharged.

Endovascular repair of infrarenal focal aortic pathology with limited aortic coverage

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR) for degenerative abdominal aortic aneurysm (AAA) requires complete aortic exclusion to prevent ongoing aneurysmal degeneration in a diseased aorta. Focal infrarenal aortic pathology, such as penetrating atherosclerotic ulcer (PAU), saccular aneurysm, and/or intramural hematoma (IMH) may not necessitate complete aortic coverage. Here, we review our experience with endovascular management of focal aortic pathology with limited aortic coverage.

METHODS

A prospectively maintained institutional database of patients undergoing EVAR was retrospectively reviewed to identify all patients treated with a nonbifurcated device (Current Procedural Terminology code: 34,800). Patients without a diagnosis of PAU, saccular aneurysm, IMH, or iatrogenic pseudoaneurysm were excluded. Medical records and imaging studies were reviewed for confirmation of focal aortic pathology. Preoperative imaging and intraoperative details were reviewed. Outcome measures included technical success, symptom-free survival, and freedom from reintervention.

RESULTS

Eight patients were identified who underwent repair of a focal aortic defect with an endovascular tube graft from 2004-2011. Six patients underwent surgery for 7 saccular pseudoaneurysms and 2 patients had iatrogenic infrarenal pseudoaneurysms. Six saccular aneurysms were associated with PAU. Seven patients (88%) were men; the median age was 76 years (range: 50-85 years). Four patients (50%) had symptoms attributable to their aneurysm (2 abdominal pain, 1 gastrointestinal symptoms, 1 lower extremity emboli). Aneurysm repair was classified as urgent in 2 patients (25%). Six patients (75%) required placement of a single aortic component, the other 2 patients (25%) required 2 components. All devices used were Zenith (Cook, Inc., Bloomington, IN) ancillary components. The median device diameter was 22 mm (range: 18-28 mm), while the median device length was 56.5 mm (range: 39-80 mm). The technical success rate was 100%. There were no early graft-related complications. All symptomatic patients experienced improvement or resolution of symptoms. In all cases, radiologic follow-up at 1 month showed stable or decreasing aneurysm size. No endoleaks were detected and no patients have required reintervention to date.

CONCLUSIONS

The optimal management of many focal infrarenal aortic defects, particularly those that are incidentally discovered, remains unclear. Our experience with endovascular repair of focal aortic pathology with limited aortic coverage suggests this approach is technically feasible and associated with excellent early results.