Successful thrombolysis of a late acute thrombotic occlusion of an aortic prosthesis after endovascular aneurysm repair

Thrombolysis for acute graft occlusion during elective endovascular aortic aneurysm repair

A 65-year-old man developed acute arterial thrombosis with stent graft occlusion, during elective endovascular aneurysm repair, with bilateral acute lower limb ischaemia. We describe successful endovascular and pharmacological management using a combination of mechanical disruption of the thrombus (using the access sheaths) followed by intra-arterial thrombolysis (Actilyse) infusion. Within 4-h the endograft had completely re-canalized. The patient made an uncomplicated recovery and was discharged on the second post-operative day.

An Unusual Case of Delayed Complete Aortic Graft Occlusion Treated by Kissing Balloon Expandable Covered Stents and Renal Chimney

Introduction

Late occlusion of the entire stent graft after endovascular aortic repair (EVAR) is a rare condition which often requires open surgery. This is a case of endovascular rescue of chronic total occlusion of an aortic stent graft in a patient at high risk of open surgery and lysis.

Report

An 82 year old male was admitted with bilateral lower limb rest pain eight years after EVAR. Endovascular relining with a covered stent under local anaesthesia was planned. Antegrade recanalisation from brachial access was achieved, then VBX balloon expandable covered stents (W. L. Gore & Associates Inc. Flagstaff, AZ, USA) were deployed in a kissing configuration to reline the occluded stent graft, alongside a double renal chimney. The post-operative period was uneventful, and a six month CT angiogram confirmed the technical success with complete patency of the aorto-iliac segment and visceral arteries.

Discussion

Complete stent graft thrombosis after EVAR is typically managed by open conversion to aortobifemoral or axillobifemoral bypass graft, surgical thrombectomy or catheter directed thrombolysis, carrying a considerable mortality and morbidity rate. Endovascular relining with kissing covered balloon expandable stents with double renal chimneys is a less invasive option. By offering a unique combination of radial strength and flexibility, associated with a trackable delivery system and a high retention capability, the GORE VBX is the present authors’ preferred stent option for this procedure. The present case shows how endovascular recanalisation by antegrade and retrograde approaches may be an effective option, especially in a patient at high risk of open surgery and lysis.

•

Late occlusion of the entire stent graft after EVAR is a rare condition.

•

It is managed by conversion to aortobifemoral or axillobifemoral bypass.

•

It can also be managed with surgical thrombectomy or catheter directed thrombolysis.

•

Endovascular rescue is an option in patients at risk of open surgery and lysis.

A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneurysm

BACKGROUND

Thrombosis of an endovascular aortic repair (EVAR) is a devastating complication of a common surgical procedure that can lead to serious morbidity and mortality if not promptly recognized. This is the first case report of an EVAR graft thrombosis in the emergency medicine literature.

CASE REPORT

We present a case of a patient with lower extremity paraplegia secondary to thrombosis of an EVAR graft who presented to the emergency room with acute stroke-like symptoms after a recent EVAR procedure. Endovascular repair of abdominal aortic aneurisms is becoming more frequent, and an increased number of patients with recent abdominal aortic aneurism repair by endovascular grafts will be evaluated by emergency physicians in the future. Emergency physicians should be aware that signs of limb ischemia, which may masquerade as acute ischemic stroke-like symptoms, is one of the more serious complications that can occur with abdominal aortic vascular grafts. Among patients with lower extremity neurological deficits in the recent setting of EVAR presenting to an emergency department, there should be a high degree of suspicion for EVAR graft thrombosis, which can be diagnosed via the gold standard of CT angiography or ultrasonography. Prompt vascular surgery consultation is essential to minimize permanent disability.