ABSTRACT
Endograft collapse caused by aortic dissection is rare, but it might cause critical complications and sometimes lead to death. We present a case of bilateral lower limb ischemia caused by endograft collapse due to type B acute aortic dissection (TBAD). A 70‐year‐old man with an abdominal aortic aneurysm (AAA) that was treated by endovascular aortic aneurysm repair (EVAR) 17 days prior returned to our hospital due to chest pain and bilateral lower limb paleness. Contrast‐enhanced computed tomography (CT) showed an aortic dissection extending from the origin of the left subclavian artery to the terminal aorta. The main body of the endograft was compressed and the aneurysm was perfused by the false lumen. Additionally, the right leg of the endograft was occluded and the left one was collapsed. The patient was treated with axillo‐bifemoral bypass without any lower limb sequela. However, contrast‐enhanced CT performed at 2 months after the onset of the TBAD showed that the main body of the endograft was still collapsed, and the aneurysm was perfused by the false lumen of the dissection; thus, open AAA repair was performed. The postoperative course was uneventful and the patient was discharged without any complications. We successfully treated the patient with bilateral lower limb ischemia caused by endograft collapse due to TBAD after EVAR. The treatment should be considered on a case‐by‐case basis and an extra‐anatomical revascularization is one of the good treatment options.
Keywords: endograft collapse, endovascular aortic aneurysm repair, lower limb ischemia, type B acute aortic dissection
Abbreviations
- AAA
abdominal aortic aneurysm
- AAD
acute aortic dissection
- CIA
common iliac artery
- CT
computed tomography
- EAB
extra‐anatomical bypass
- EIA
external iliac artery
- EVAR
endovascular aortic aneurysm repair
- EVT
endovascular treatment
- IBE
iliac branch endoprosthesis
- IIA
internal iliac artery
- SCA
subclavian artery
- TAA
thoracic aortic aneurysm
- TBAD
type B acute aortic dissection
- TEVAR
thoracic endovascular aortic repair
Summary.
Endograft collapse after endovascular aortic aneurysm repair caused by aortic dissection is rare, but might cause critical complications and sometimes lead to death.
We successfully treated the patient with a staged operative procedure.
There is currently no established treatment for this condition and treatment should be considered on a case‐by‐case basis.
1. Introduction
Acute aortic dissection after endovascular aortic aneurysm repair (EVAR) can occasionally occur. Kpodonu et al. [1] reported an incidence rate of 2.4% for retrograde aortic dissection after EVAR. However, endograft collapse caused by aortic dissection rarely occurs. The endograft collapse might cause critical complications and sometimes lead to death. We present a case of type B acute aortic dissection (TBAD) after EVAR resulting in lower limb ischemia, which was successfully treated by a two‐stage operation.
2. Case Report
A 70‐year‐old man presented to our hospital with complaints of chest pain and bilateral lower limb paleness. The patient had undergone EVAR for an infrarenal abdominal aortic aneurysm (AAA) using GORE EXCLUDER devices (W. L. Gore & Associates, Flagstaff, AZ, USA) 17 days prior to presentation. The proximal neck had a tapered shape, as the narrowest, and thickest parts were 22 and 28 mm, respectively, in size. The length of the proximal neck was relatively long, with a length of 52 mm; thus, the main body with a diameter of 28.5 mm was selected. Moreover, we planned to preserve the left internal iliac artery (IIA) using the iliac branch endoprosthesis (IBE), since the left common iliac artery (CIA) had an aneurysm, considering the need for treatment when the right CIA develops an aneurysm in the future because of the dilated right CIA (Figure 1). The operation was successfully performed. Postoperative contrast‐enhanced computed tomography (CT) showed no endoleak and an AAA diameter of 51 mm, which is of the same size as that before the EVAR. There were no other abnormalities, except for a thoracic aortic aneurysm (TAA), which is 50 mm in diameter, which did not change from that observed before the EVAR. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day.
FIGURE 1.
(A) Preoperative computed tomography (CT) showed an infrarenal abdominal aortic aneurysm (AAA) whose maximum diameter is 51 mm (arrowhead). The proximal neck had a constricted shape, as the narrowest and thickest parts were 22 and 28 mm in size. The right CIA was dilated to 22 mm, and the left CIA had a 30‐mm aneurysm. It also showed a 51‐mm TAA (arrow). (B) The final intraoperative angiography showed the treated AAA with the endograft including the Iliac Branch Endoprosthesis, and the inferior mesenteric artery embolization. A slight type 2 endoleak from the lumbar artery was present, but no dissection was detected.
Contrast‐enhanced CT in the emergency room showed an aortic dissection extending from the origin of the left subclavian artery (SCA) to the terminal aorta (Figure 2A). The main body of the endograft was compressed by the false lumen of the dissection, with the right leg occluded and the left leg collapsed (Figure 2B,C). The AAA had a diameter of 51 mm, which was of the same size as that observed prior to the EVAR, although had the contrast effect from the false lumen. A diameter of the TAA was 50 mm, unchanged from before the EVAR.
FIGURE 2.
(A) Computed tomography showed an aortic dissection extending from the origin of the left SCA to the terminal aorta, with the entry site located at the aortic arch (arrow). The AAA had a diameter of 51 mm (black outlined arrow), with a size similar to that observed before the EVAR, although a contrast effect from the false lumen was present. The diameter of the TAA (arrowhead) was 50 mm, which was similar to that observed before the EVAR. (B) The main body of the endograft was compressed by the false lumen of the dissection (arrow). (C) The right leg of the endograft was occluded and the left one was collapsed (arrow).
We decided to perform an extra‐anatomical bypass (EAB) to treat the bilateral lower limb ischemia, considering that no other malperfusion was present at that time, and the diameter of the thoracic aorta in our case was too large to perform thoracic endovascular aortic repair (TEVAR). The patient underwent an emergency axillo‐bifemoral bypass (AxFB). The postoperative course was uneventful and the patient had no lower limb sequela. However, the follow‐up contrast‐enhanced CT performed approximately 2 months after the onset of the TBAD showed that the endograft was still collapsed and that the AAA with a diameter of 52 mm was perfused from the false lumen. Thus, we decided to perform an open surgery to manage the dissected AAA.
Under general and epidural anesthesia, Y‐grafting was performed (Figure 3A). The main body and the right leg of the endograft were explanted. A 20 mm × 9 mm bifurcated Dacron graft (J Graft Shield, Japan Lifeline Co. Ltd., Japan) was used, and a proximal anastomosis was made in an end‐to‐end fashion at just below the left renal artery. End‐to‐end distal anastomoses were made at the right external iliac artery (EIA) just below the bifurcation of the EIA and IIA, and the left endograft leg. The right IIA was reconstructed with graft interposition; thus, the bilateral IIA was preserved, to reduce the risk of ischemic colitis, gluteus claudication, sexual dysfunction, and spinal cord injury especially if additional thoracic aortic intervention was required in the future. After revascularization by Y‐grafting, the AxBF bypass was ligated on the right side of the abdomen and the AxBF graft itself was left.
FIGURE 3.
(A) An intraoperative image showing a proximal anastomosis made just below the left renal artery. Distal anastomoses were made with the EIA on the right and the endograft on the light to preserve the iliac branch endoprosthesis. Moreover, the right IIA was reconstructed. (B) Postoperative computed tomography showed no significant change in the dissection from the left SCA to the proximal anastomosis, and no abnormalities were observed in the anastomosis or residual endograft.
Postoperative contrast‐enhanced CT showed no significant change in the dissection from the left SCA to the proximal anastomosis, and no abnormalities were observed in the anastomosis or residual endograft (Figure 3B). The patient was discharged on the ninth postoperative day with an uneventful postoperative course.
3. Discussion
The endograft collapse due to the TBAD is a rare complication of EVAR, but serious and potentially life threatening. In our literature review, we found reported 15 cases with this complication.
Of the 15 reported cases, 14 were male and the average age was 71 years (53–92 years). The median time from EVAR to TBAD was 18 months (48 h–10 years). Their main complaints were chest and back pains, limb ischemia, and abdominal pain, and one patient had cardiopulmonary arrest. The endografts used in EVAR were EXCLUDER (W. L. Gore & Associates, Flagstaff, AZ, USA) in eight cases, Zeniths (Cook Medical Inc., Bloomington, IN, USA) in four cases, and Endurant (Talent) (Medtronic Cardiovascular, Santa Rosa, CA, USA) in three cases. The treatments were EAB in six cases, and endovascular treatment (EVT) in seven cases. Two cases without treatment died. Eleven cases were alive, but four cases died. The details of these cases are shown in (Table 1) [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15].
TABLE 1.
Cases of endograft collapse due to type B aortic dissection reported in the literature.
| Years published | First author | Age | sex | Collapsed device | Endograft location | Time after EVAR | Treatment | Symptoms | Outcome |
|---|---|---|---|---|---|---|---|---|---|
| 2003 | Haulon [2] | 53 | F | Excluder (Gore) | Infrarenal AAA | 6 months | Patient died en route | Bilateral lower extremity pain, paresthesia, cardiac arrest | Dead |
| 2009 | Iyer [3] | 77 | M | Zenith Flex (Cook) | Infrarenal AAA | 11 weeks | TEVAR and thrombectomy | Upper abdominal and back pain, bilateral lower extremity ischemia | Alive |
| 2009 | van Keulen [4] | 74 | M | Talent (Medtronic) | AAA | 18 months |
TEVAR and stenting for collapsed endograft main body |
Abdominal pain | Alive |
| 2011 | Tolenaar [5] | 92 | M | Endurant (Medtronic) |
Pseudoaneurysm after Y‐grafting for AAA |
48 h | Percutaneous balloon fenestration | Uncontrollable interscapular pain | Alive |
| 2014 | Psacharopulo [6] | 75 | M | Excluder (Gore) | Infrarenal AAA | 14 months | EAB | Abdominal and back pain, bilateral lower extremity ischemia | Dead |
| 2014 | Vainas [7] | 88 | M | Zenith (Cook) | Infrarenal AAA | 10 years | EAB → open abdominal aortic repair and TEVAR | Bilateral lower extremity pain | Alive |
| 2015 | Yoshiga [8] | 69 | M | Endurant II (Medtronic) | AAA | 6 months | TEVAR and iliac leg insertion | Thoracoabdominal pain | Alive |
| 2017 | Goto [9] | 65 | M | Excluder (Gore) | AAA | 2 years | EAB | Paraplegia | Alive |
| 2017 | Itoga [10] | 59 | M | Excluder (Gore) | Right CIA aneurysm | 4 years | TEVAR and thrombectomy | Bilateral buttock stabbing discomfort | Alive |
| 2018 | Nomura [11] | 73 | M | Zenith (Cook) | AAA | 7 years | Died in ambulance | Lower back pain | Dead |
| 83 | M | Excluder (Gore) | AAA | 6 months | EAB | Back pain and lower limb ischemia | Dead | ||
| 2019 | Ostapenko [12] | 71 | M | Zenith (Cook) | AAA | Several years | TEVAR | Chest and back pain with left lower extremity ischemia | Alive |
| 2019 | Nagatomi [13] | 64 | M | Excluder (Gore) | AAA | 21 months | EAB | Back, abdominal, and limb pain | Alive |
| 2020 | Motoji [14] | 62 | M | Excluder (Gore) | Infrarenal AAA | 3 years | EAB → open abdominal aortic repair | Acute back pain and paresthesia of the lower limbs | Alive |
| 2022 | Cooke [15] | 60 | M | Excluder (Gore) | Right CIA aneurysm | 16 months | TEVAR, abdominal aortic cuff, and iliac stenting | Chest, back, abdominal, and bilateral lower extremity pain with a cool left foot | Alive |
Abbreviations: AAA, abdominal aortic repair; EAB, extra‐anatomical bypass; TEVAR, thoracic endovascular repair.
The cause of TBAD after EVAR is unknown, but previous reports [5, 6, 8, 15, 16, 17] have suggested several factors, such as anatomical factors including angulation of the proximal neck, calcification in the region just above the level of the renal arteries, a fragile aortic wall, and a penetrating ulcer. Technically, wire manipulation and balloon touch up can lead to a direct injury of the aorta. Regarding the device, excessive oversizing should be avoided. Moreover, anchor barbs were reported to have been the cause of dissection. Of course, spontaneous TBAD can happen since patients with AAA also have an increased risk of AAD.
We suspect that our case was a spontaneous TBAD for several reasons. First, we performed the surgery with great care to ensure the wire did not reach the aortic arch. Second, the CT performed right after the surgery did not reveal any dissection. Third, the patient had already had a TAA before EVAR and the entry site was just below the left SCA, the predilection site of the spontaneous dissection. Fourth, the patient had very poor blood pressure control after discharge. Contrarily, the onset of the TBAD was approximately 2 weeks after EVAR, its relevance to EVAR cannot be denied. The factors are not always singular but are often interrelated.
The cause of whether the endograft collapses or not due to dissection is unclear. Although some reports [6, 8, 10, 13, 15] have suggested that it is affected by several factors, such as the false lumen pressure on the endograft, strength of the false lumen wall, and endograft pressure. Owing to these factors, when the pressure of the false lumen exceeds the radial force of the endograft, the endograft collapses.
In this case, we assumed the false lumen pressure was high because the endograft prevented re‐entry, and the main body might be easily enfolded since the proximal neck was slightly oversized.
There are no established treatments for cases of endograft collapse after EVAR. The treatment goals are threefold, which are as follows: reperfusion of the lower limbs and treatment of the dissection and aneurysm. The first priority is to eliminate the ischemia, and one‐, or two‐stage treatment can be considered depending on the patients' condition. Specifically, the EAB, laparotomy, and EVT are the treatment options, as described previously [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]. Each of these treatments has advantages and disadvantages. The EAB is easy, minimally invasive, and reliable, but further treatment of the dissection and aneurysm may be required. With laparotomy, we can treat the lower limb ischemia and AAA at once. However, it is highly invasive and difficult, and additional intervention may be required for the TBAD. This surgery is too invasive to be the first choice usually, especially in emergency cases. EVT including TEVAR, thrombectomy, and stenting are good options. There are several reports [3, 4, 5, 8, 10, 12, 15] of successful treatments of endograft collapse with EVT, although, in some cases, the treatments are not anatomically or technically suitable.
We initially performed an EAB to reestablish the lower limb blood flow in the present case, because, unfortunately, the diameter of the thoracic aorta in our case was too large to perform TEVAR. Moreover, obtaining blood access and wire manipulation were difficult, which led to prolonged operative time and delayed recirculation of the lower limbs. The patient had no sequelae in the lower limbs after the AxFB, but the endograft remained collapse even after the conservative treatment of the TBAD. The laparotomy for the AAA was performed in two stages. The postoperative course after both surgeries was uneventful, and we considered this strategy as successful. We still need to follow‐up if the thoracic aorta would dilate in the future.
4. Conclusion
We successfully treated a case of bilateral lower limb ischemia caused by endograft collapse with a staged operative procedure; we initially performed AxFB to recirculate the lower limbs and secondly conducted open abdominal aortic repair to treat the dissected AAA. There is currently no established treatment for such cases, but treatment should be considered on a case‐by‐case basis.
Author Contributions
Wakiko Hiranuma: project administration, writing – original draft. Tadanori Minagawa: writing – review and editing. Takuya Shimizu: writing – review and editing. Shunsuke Kawamoto: supervision.
Ethics Statement
This case report has been approved by the Institutional Review Board of Tohoku Medical and Pharmaceutical University Hospital.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
We thank Enago (https://www.enago.jp) for English language editing.
Funding: The authors received no specific funding for this work.
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this case report.
References
- 1. Kpodonu J., Preventza O., Ramaiah V. G., et al., “Retrograde Type A Dissection After Endovascular Stenting of the Descending Thoracic Aorta. Is the Risk Real?,” European Journal of Cardio‐Thoracic Surgery 33 (2008): 1014–1018, 10.1016/j.ejcts.2008.03.024. [DOI] [PubMed] [Google Scholar]
- 2. Haulon S., Greenberg R. K., Khwaja J., et al., “Aortic Dissection in the Setting of an Infrarenal Endoprosthesis: A Fatal Combination,” Journal of Vascular Surgery 38 (2003): 1121–1124, 10.1016/S0741-5214(03)00931-5. [DOI] [PubMed] [Google Scholar]
- 3. Iyer V., Rigby M., and Vrabec G., “Type B Aortic Dissection After Endo‐Vascular Abdominal Aortic Aneurysm Repair Causing Endograft Collapse and Severe Malperfusion,” Journal of Vascular Surgery 50 (2009): 413–416, 10.1016/j.jvs.2009.03.060. [DOI] [PubMed] [Google Scholar]
- 4. van Keulen J. W., Toorop R. J., de Borst G. J., et al., “Abdominal Stent‐Graft Collapse Due to Progression of a Stanford Type B Dissection,” Journal of Endovascular Therapy 16 (2009): 752–754. [DOI] [PubMed] [Google Scholar]
- 5. Tolenaar J. L., van Keulen J. W., Vonken E. J., van Herwaarden J. A., Moll F. L., and de Borst G. J., “Fenestration of an Iatrogenic Aortic Dissection After Endovascular Aneurysm Repair,” Journal of Endovascular Therapy 18 (2011): 256–260, 10.1583/10-3330.1. [DOI] [PubMed] [Google Scholar]
- 6. Psacharopulo D., Ferrero E., Viazzo A., Ferri M., Ripepi M., and Nessi F., “Abdominal Aortic Endograft Collapse due to False Lumen Radial Force of an Acute Type B Aortic Dissection,” Annals of Vascular Surgery 2014, no. 28 (1931): e9–e12, 10.1016/j.avsg.2014.06.067. [DOI] [PubMed] [Google Scholar]
- 7. Vainas T., Tielliu I. F., Wallis de Vries B. M., et al., “Acute Type B Dissection Complicated by Infrarenal Aortic Stent‐Graft Collapse With Spontaneous Re‐Expansion,” Journal of Endovascular Therapy 21 (2014): 353–355, 10.1583/13-4595L.1. [DOI] [PubMed] [Google Scholar]
- 8. Yoshiga R., Morisaki K., Matsubara Y., et al., “Emergency Thoracic Aortic Stent Grafting for Acute Complicated Type B Aortic Dissection After a Previous Abdominal Endovascular Aneurysm Repair,” Surgical Case Reports 1 (2015): 99, 10.1186/s40792-015-0096-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Goto Y., Hosoba S., Ogawa S., and Kinoshita Y., “Collapsed Stent Graft and Severe Malperfusion 2 Years After Endovascular Aortic Repair,” European Journal of Cardio‐Thoracic Surgery 52 (2017): 599–600, 10.1093/ejcts/ezx195. [DOI] [PubMed] [Google Scholar]
- 10. Itoga N. K., Wu T., Dake M. D., Dalman R. L., and Lee J. T., “Acute Type B Dissection Causing Collapse of EVAR Endograft and Iliac Limb Occlusion,” Annals of Vascular Surgery 46, no. 206 (2018): e201–e204, 10.1016/j.avsg.2017.07.024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Nomura Y., Nagao K., Hasegawa S., et al., “Fatal Complications of New‐Onset Complicated Type B Aortic Dissection After Endovascular Abdominal Aortic Aneurysm Repair: Report of 2 Cases and Literature Review,” Vascular and Endovascular Surgery 53 (2019): 255–258, 10.1177/1538574418819540. [DOI] [PubMed] [Google Scholar]
- 12. Ostapenko A., Richard M. N., and Dietzek A. M., “Rare Case of Acute Type B Dissection Causing Complete Collapse of EVAR Stent,” Vascular and Endovascular Surgery 53 (2019): 420–423, 10.1177/1538574419840873. [DOI] [PubMed] [Google Scholar]
- 13. Nagatomi S., Yamamoto H., Toyokawa K., et al., “Stent‐Graft Re‐Expansion Following Axillo‐Bifemoral Bypass: A Case of Stent Graft Collapse Due to Acute Type B Aortic Dissection,” Journal of Cardiovascular Surgery 48 (2019): 206–209. [Google Scholar]
- 14. Motoji Y., Kato T., Seki J., Tsumura K., Tomita S., and Okawa Y., “A Case of Collapsed Stent Graft, Severe Lower Limb Ischemia, and Ruptured Abdominal Aortic Aneurysm Due to Type B Acute Aortic Dissection 3 Years After Endovascular Aneurysm Repair,” Annals of Vascular Diseases 13 (2020): 308–311, 10.3400/avd.cr.19-00142. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Cooke V. P., Bai H., George M. J., et al., “Collapsed Endograft and Lower Limb Ischemia From Type B Dissection Repaired With Thoracic Endovascular Aortic Graft and Iliac Stenting: A Case Report and Review of the Literature,” Journal of Vascular Surgery Cases and Innovative Techniques 8 (2022): 256–260, 10.1016/j.jvscit.2022.02.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Rodriguez Czaplicki E. J., Martinez Mira C., Anaya Sifuentes D. M., and Aisa Aldama J., “Acute Type B Aortic Dissection One Month After Fenestrated EVAR Procedure,” EJVES Short Reports 44 (2019): 38–43, 10.3400/avd.cr.20-00107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Sirignano P., Pranteda C., Capoccia L., Menna D., Mansour W., and Speziale F., “Retrograde Type B Aortic Dissection as a Complication of Standard Endovascular Aortic Repair,” Annals of Vascular Surgery 29, no. 127 (2015): e5–e9, 10.1016/j.avsg.2014.08.011. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this case report.