Fenestrated-branch endovascular repair (FEVAR) for para-anastomotic huge aortic pseudo-aneurysm: Case report

Abstract

Introduction and importance

Anastomotic aortic pseudoaneurysm is a rare, late, and fatal complication after open surgery to repair an abdominal aneurysm. Treatment can be challenging in complex cases, especially renal and visceral arteries. A common solution is the fenestrated endograft, which has branches that accommodate these vital vessels. Sometimes, due to the position of the pseudoaneurysm and its proximity to visceral arteries, especially renal arteries, open repair would be challenging; therefore, an endovascular approach could be a safer option.

Case presentation

A patient was admitted 10 years after open surgical repair of an abdominal aortic aneurysm. The pseudoaneurysm was successfully treated with a four-fenestration endovascular repair (fEVAR) extending to the previous abdominal tube graft, and the patient recovered well.

Clinical discussion

Para-anastomotic aortic pseudoaneurysms are rare but challenging, demanding complicated management due to visceral artery involvement. Treatment options include open repair, endovascular techniques (e.g., fEVAR or stent grafts), and minimally invasive approaches such as thrombin injection, with case studies indicating successful results. Still, there is limited evidence available on optimal strategies.

Conclusion

Fenestrated endovascular aortic repair after previous open surgery is associated with low perioperative complications and reasonable medium-term survival rates.

Highlights

• •Anastomotic aortic pseudoaneurysm challenging case involving renal and visceral arteries.
• •Fenestrated endografts are a safer solution, when pseudoaneurysms are near visceral arteries.
• •A patient 10 years after open AAA repair with a pseudoaneurysm successfully managed with endovascular repair (fEVAR)
• •Fenestrated endovascular aortic repair (fEVAR): Lower perioperative complications and Reasonable survival rates

1. Introduction

Abdominal aortic aneurysm refers to a growing, persistent abdominal aortic dilation [1]. This condition can cause severe morbidity and mortality. Conventionally, open surgical repair is the treatment for abdominal aortic aneurysm. [2]. Endovascular aneurysm repair has been introduced as an alternative to open surgery. Long-term benefits from endovascular versus open surgical repair for abdominal aortic aneurysm (AAA) are still unproven. [3]. Short- and long-term complications and risks have been reported for both methods. Pseudoaneurysm after open surgery is an uncommon complication. The incidence of pseudoaneurysm development after grafting is approximately 1–6 %, increasing to 23–27 % at 15 years. [4] The progression of the degeneration in the native aorta is associated with this complication. In patients with previous open repair, there is a high risk of complications for redo open surgery; therefore, less invasive methods have been suggested, such as hybrid repair with visceral vessels retrograde bypass and endovascular thoracoabdominal aortic aneurysm (TAAA) exclusion. [5] Due to the complex position of the pseudoaneurysm, the treatment plan could be challenging, for instance, involving renal and visceral arteries. The fenestrated endograft is one of the most common solutions to this challenge. The side branches and holes facilitate the incorporation of the visceral and renal arteries. [6].

This case report has been reported in line with the SCARE checklist. [7]

2. Case presentation

A 66-year-old man walked into the emergency department with abdominal pain 10 years after open surgical repair of an abdominal aortic aneurysm. His medical history included myocardial infarction and triple coronary artery bypass grafting 11 years earlier. The patient has an implantable cardioverter-defibrillator (ICD) with a left ventricular ejection fraction (LVEF) of 20 %. Vital signs were stable, and in the physical examination, a scar from previous surgery was observed. Abdominal aortic pulse was present, as well as the pulses in the distal limbs. Differential diagnoses for this patient were considered, such as abdominal aortic aneurysm, pseudoaneurysm, bowel obstruction, kidney stones, PUD, etc. In the CT angiography, a pseudoaneurysm at the anatomic site was discovered. 57 mm para-renal anastomotic saccular pseudoaneurysm, following open surgery repair. The landing zone was placed 14 mm to the superior mesenteric artery, facing the renal arteries caudally. The intraluminal diameter was 17 mm in the visceral aorta. The Dacron tube graft was noted in the inferior abdominal aorta. Short common iliac arteries bilaterally and mildly tortuous common iliac arteries and external iliac arteries were observed in the imaging study. Standard endovascular aneurysm repair (EVAR) or even double chimney endovascular aneurysm repair CHEVAR was not possible due to juxtarenal pathology and a short landing zone to the superior mesenteric artery (SMA) (Fig. 1). T-branch branched endovascular aneurysm repair (BEVAR) was not possible because of the small internal luminal diameter in the visceral aorta. Alternative treatment options, such as thrombin injection and coil embolization, are not standard in this context and are more appropriate for smaller or peripheral pseudoaneurysms. The pseudoaneurysm was managed successfully with four-fen fenestrated endovascular aneurysm repair (FEVAR) extended to the previous abdominal tube graft. The case was conducted using ZFEN-CMD, 7*22 mm V12 for the superior mesenteric and celiac, and 6*22 mm for the renal arteries. (Fig. 2, Fig. 3) The surgery was done in about 5 h, with around 150 cc of contrast and 12,500 units of heparin. The RABBE guiding sheaths were a bit stiff, and so the right renal artery was cannulated and stented from above, and the celiac was not wired until the other stents were deployed and flared. Finally, at the end of the procedure, the right renal artery sheath was withdrawn to stent off the celiac artery after device deployment. The patient recovered post-operatively in the ICU, then after a few days in the vascular ward. The patient was discharged in stable condition after an uneventful recovery. He was followed with CT angiography after 1, 3, 6, and 12 months; no endoleak was seen in these follow-ups. (Fig. 4, Fig. 5, Fig. 6, Fig. 7, Fig. 8).

Fig. 1.

Reconstructed CT-angiography images of the patient's pseudoaneurysm.

Fig. 2.

Endovascular Planning of the graft.

Fig. 3.

Graft Properties Scheme.

Fig. 4.

Follow-up CT angiography 3 months post-op op.

Fig. 5.

follow-up CT angiography 3 months post-op.

Fig. 6.

follow-up CT angiography 3 months post-op.

Fig. 7.

follow-up CT angiography 3 months post-op

Fig. 8.

follow-up CT angiography 3 months post-op.

3. Discussion

Para-anastomotic pseudoaneurysm after open abdominal aortic repair is a rare but fatal complication. Management is complex and more challenging because of visceral and renal artery involvement. The available treatments for this condition include open surgical repair, endovascular repair, induction of thrombosis in the pseudoaneurysm sac via direct thrombin injection, and coil embolization.

Open surgical repair is a definitive treatment option, particularly in anatomically complex cases. This approach involves resection of the pseudoaneurysm followed by graft interposition or resection of an abdominal aortic pseudoaneurysm (AAP) combined with aortic repair using a lateral Dacron patch aortoplasty, as detailed by Pisters et al. in their study involving a pediatric patient [[8], [9], [10]].

Endovascular procedures such as fenestrated endovascular aneurysm repair (FEVAR) and stent grafts, and bifurcated endoprostheses have gained attention, especially in patients who are high risk and not suitable for open approaches.

There have been few reports about the endovascular repair of pseudoaneurysm after open surgery. White et al. [11] have described a similar case. In this case, the patient was not suited for open surgery due to cardiac comorbidities. Therefore, the endovascular repair was preferred. The complex nature of this case required a careful and sophisticated solution to avoid postoperative morbidities and mortality. Hence, fenestrated endovascular aneurysm repair (fEVAR) was an effective treatment.

Chase et al. [12] presented a case involving a traumatic pseudoaneurysm of the suprarenal abdominal aorta, which manifested with epigastric pain and obstructive jaundice. The patient underwent intraluminal patch aortoplasty, which successfully alleviated the biliary obstruction. Endovascular repair for the treatment of aortic pseudoaneurysm (AAP) has been documented through the utilization of stent grafts in two case reports, as well as the application of a balloon-expandable bifurcated endoprosthesis in additional cases [[13], [14], [15]]. Geckeis et al. [16]) reported the case of a 63-year-old male patient who developed a substantial pseudoaneurysm in the abdominal aorta following surgical fenestration and patch aortoplasty for acute type B aortic dissection. The patient received a trans-catheter delivery of 1500 thrombin units, which resulted in the complete thrombosis of the pseudoaneurysm sac.

The literature presents limited cases of alternative treatments other than open surgical or endovascular repair. Minimally invasive and alternative techniques, such as direct thrombin injection and intraluminal patch aortoplasty, have been utilized for select patients.

Oner et al. [15] reported a case involving a post-traumatic abdominal aortic pseudoaneurysm (AAP) that developed eight months following a stabbing incident to the back and right flank. The pseudoaneurysm was situated near the iliac bifurcation. The authors opted to deploy a bifurcated endovascular graft stent, specifically the TriVascular Ovation stent, effectively addressing the condition.

4. Conclusions

Pseudoaneurysm is a rare but life-threatening complication after repair surgery of an abdominal aortic aneurysm, which can be managed with endovascular procedures, especially in patients who are not fit for open-repaired surgery due to comorbidities. Fenestrated endovascular aortic repair after prior open surgical repair is associated with low perioperative morbidity and mortality and acceptable medium-term survival.

Informed consent

Informed consent was acquired from the patient.

Author contribution

Dr. Javad Salimi: Study Concept and design.

Dr. Ghazal Dahaghin: writing the paper.

Dr. Siamak Mousazadeh: Study Concept and design.

Dr. Afshin Bighamian: Study Concept and design, writing the paper.

Ethical approval

The study is exempt from ethical approval in this institution for case reports due to regulations. (Tehran university of medical sciences).

Funding

There was no source of funding.

Guarantor

Afshin Bighamian

Declaration of competing interest

The authors declare that there are no conflicts of interest regarding the publication of this work. No financial, personal, or professional relationships could be perceived to influence the research, analysis, or conclusions presented in this manuscript.