Endovascular Treatment of a Late Complication of an Open Repair of Abdominal Aortic Aneurysm
- 1. Medical School – Universidade Luterana do Brasil, Porto Alegre, Brazil
- 2. Medical School – Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
- 3. Hospital de Clínicas de Porto Alegre – Federal Universityof Rio Grande do Sul, Porto Alegre, Brazil
Abstract
Abdominal aortic aneurysms (AAA) are the most common type of aortic aneurysms. Traditionally it has been treated by open surgical repair (OSR), but in the last years endovascular repair (EVAR) became the first choice treatment in patients with suitable anatomy. Although the mortality and morbidity are lower with EVAR, late complications, such as endoleaks, remain a problem. Late complications after OSR are less frequent than after EVAR, but they still occur. We report a case of a patient with an uncommon late complication after OSR: limb occlusion of the Dacron prosthesis of an aortobifemoral bypass 14 years after. The rescue was performed by an unusual, but successful, urgent endovascular approach using intra-arterial thrombolysis with recombinant tissue plasminogen activator(r-tPA) followed by covered stents implantation in the Dacron limb prosthesis and balloon angioplasty in the origin of a previous saphenous vein femoropopliteal bypass grafting. Late complications after EVAR and OSR, as well as treatment options, are discussed here.
Citation
Saadi MP, Saadi RP, Tagliari AP, Saadi EK (2016) Endovascular Treatment of a Late Complication of an Open Repair of Abdominal Aortic Aneurysm. JSM Gastroenterol Hepatol 4(3): 1065.
Keywords
Abdominal aortic aneurysm , Endovascular treatment , Open surgical repair , Late complication , Limb occlusion of aortobifemoral bypass
ABBREVIATIONS
OSR: Open Surgical Repair; AAA: Abdominal Aortic Aneurysm; EVAR: Endovascular Repair; rtPA: Recombinant Tissue Plasminogen Activator.
INTRODUCTION
Abdominal Aortic Aneurysm (AAA) is the most common type of aneurysm and it is lethal if untreated [1]. Until 1991, the only treatment option was open surgical repair (OSR). However, in 1991, the management began to change when endovascular aneurysm repair (EVAR) technique emerged as a less invasive alternative [2]. Nowadays, EVAR technique has become the firstline treatment of AAA in many centers around the world [3].
It has been reported that, although the OSR has more early postoperative complications (30 days), the long term complications (beyond 30 days) are rare [1,4,5]. Endoleaks and, as a consequence, further reinterventions, are the Achilles heel of EVAR. Nevertheless, the long-term mortality (6 years) is equal in both groups [4]. Although less frequent than after EVAR, open repair sometimes needs late interventions, that’s why it’s advised lifelong surveillance. Here we present an uncommon case: a limb occlusion of an aortobifemoral bypass – a late postoperative complication of an OSR of an AAA, which was corrected by an unusual endovascular approach.
CASE PRESENTATION
A 64 year old male was admitted in our hospital with critical limb ischemia. He had several previous cardiovascular interventions: aortobifemoral bypass 14 years ago for an infra renal abdominal aortic aneurysm associated with iliac occlusive disease; right femoropopliteal bypass (saphenous vein above the knee) 8 years ago; and coronary stents 6 years ago.
The patient was asymptomatic until 3 days before going to emergency room, when he started with sudden rest pain in his right leg. The patient was anxious and restless, his right femoral and distal pulses were absent, and his right leg was pale. Doppler ultrasound demonstrated occlusion of the right limb of the aortobifemoral bypass and low flow (20 m/sec) in the right femoropopliteal bypass.
He was immediately transferred to the hybrid room and underwent an emergency endovascular approach. The occluded right limb was accessed by the left brachial artery and by retrograde approach in the right femoral artery, which was pulseless. An aortography was performed with a pigtail from the arm and confirmed total occlusion of the previous right limb of the aortobifemoral bypass (Figure 1). The recanalization was done from the arm with a 0,035 hydrophilic guide wire RoadrunnerCookR. An intra- arterial trans procedure local thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) through a multiperforated catheter was performed (Figure 2).
Another aortography after thrombolysis demonstrated significant improvement of the right artery flow and a tight stenosis at the origin of the femoropopliteal bypass saphenous vein graft (Figure 3).
The endovascular technique employed was: Shuttle-CookR 8 F through the left arm and 2 Viabahns-GoreR 7x15 implanted inside the right limb of the aortobifemoral bypass; balloon accommodation (6x120) of the ViabahnsR (Figure 4); baloon angioplasty (8x20) of the origin of the right limb; balloon angioplasty (6x20) of the origin of the femoropopliteal bypass (Figure 5).
The patient had immediate pain relief and normal distal pulses after procedure. He was discharged from the hospital next day with clopidogrel and aspirin. An angiotomography was performed 30 days after the procedure, which demonstrated normal flow in the aortofemoral bypass and in the right femoropopliteal bypass grafting as well (Figures 6,7).
DISCUSSION
Open surgical repair of AAA is associated with greater early mortality and morbidity than EVAR. The most common complications of OSR are bleeding (21.7%), incisional hernia (21.7%) and colonic ischemia (30.4%).Mortality associated to those complications is 23% [3]. For this reason, the outcome of the EVAR is better in the immediate post operatory period. On the other hand, late complications are very uncommon in OSR patients and much more common in EVAR patients. Approximately sixtyseven percent of late EVAR complications were endoleaks, 11.5% prosthesis migration and 11.5% occlusion. Therefore, follow-ups demonstrate that the long-term mortality is similar between the two groups [6].
A study demonstrated that7.9% of EVAR patients require are intervention and 5.8% requires multiple reinterventions. This has been questioned and became the Achilles heel of endovascular interventions. By the other hand, just 3.6% of OSR patients require one reintervention and 1.6% requires multiple reinterventions [3]. Although OSR patients don’t have as many late complications as EVAR, surveillance is needed because a considerable number of complications do exist.
Occlusion of the prosthesis is rare complication after conventional AAA repair and it is usually caused by coexistent iliac occlusive disease. The DREAM trial - a randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms- followed 178 open and 173 EVAR cases and found a total of 3 occlusions after open repair and 12 after EVAR [7]. Treatment of graft thrombosis can be performed with open or endovascular approach. Intra-arterial thrombolysis is being increasingly used in the graft acute thrombosis context, with good results [8,9].
A recent study of EVAR, with the ViabahnR stent for complex aortoiliac occlusions, compared to OSR showed that the primary occlusion rate was 0.58/100 person-years in the EVAR group and 0.31 in the OSR group. No significant difference in primary patency of the limb at 2 years of follow-up, was found between the groups (94% in the EVAR group vs 97% in the OSR group, p =0.50). The average hospital length of stay was shorter for patients treated with EVAR and the complication rate was 4% for EVAR vs 18% for OSR (p=0.32).The authors consider that the ViabahnR has four main advantages: (1) it is a covered stent, providing a direct barrier to the in growth of neointimal hyperplasia;(2) it is extremely flexible, minimizing the risk of occlusion due to kinking in the tortuous external iliac artery; (3) it is low profile, allowing the 7-mm and 8-mmdevices to be deployed via a 7F introducer sheath [10]; (4) it has long lengths up 10 cm and 15 cm and more recently 20 cm, reducing the cost impact of using multiples grafts.
We report a case of serious late complication after conventional AAA repair that was treated successfully with endovascular therapy. It was an acute occlusion of the right limb of an aortobifemoral bypass performed 14 years ago. There are many treatment options, but we decided for an endovascular approach with thrombolysis and covered stent implantation (ViabahnR) inside the occluded limb. We preferred a covered stent to avoid distal embolization and for the possible better long term permeability. There are a few studies showing good results when covered stents ere used to treat extensive aortoiliac disease but long-term results are not currently available [11,12]. An alternative treatment would have been balloon expandable covered stents such as ATRIUM V12R but we didn’t have it immediately available at that time in the hybrid room and they are shorter in length. The patient also had a severe stenosis at the origin of the saphenous vein graft used for previous femoropopliteal bypass 8 years ago, which was treated by balloon angioplasty. Probably this stenosis contributed to the occlusion of the right limb of the aortofemoral bypass because of bad distal runoff. We decided not to stent because it was located in a possible bending zone.
In conclusion, the treatment options in patients with aortic disease should be individualized and considered complementary and not competitive.
