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

Abstract

We report a case of stent graft occlusion, severe lower extremity ischemia, and ruptured abdominal aortic aneurysm due to type B acute aortic dissection 3 years after endovascular aneurysm repair. He admitted our hospital because of abrupt back pain and dysesthesia of bilateral lower limb. Contrast-enhanced computed tomography (CT) scan showed type B acute aortic dissection and occlusion of the stent graft due to dynamic compression by the false lumen. Emergent right axillo-bifemoral bypass operation was done for his critical limb ischemia. Immediately after the successful operation, he fell into shock vital and dissecting abdominal aortic aneurysm rupture was revealed by CT scan. We performed the stump occlusion of the infrarenal abdominal aorta and the bilateral common iliac arteries by abdominal midline incision. Postoperative myonephropathicmetabolic syndrome due to the left ischemia resulted in amputation of his left lower leg for lifesaving. While EVAR cases are increasing, various its complications come to be reported. We consider that this case report might be cautious about the indication of EVAR for the younger generation. (This is a translation of Jpn J Vasc Surg 2019; 28: 367–371.)

Hybrid repair strategies for acute type B aortic dissection complicating prior standard and complex endovascular aortic repair

“…Open repair was performed in two cases, including one aortobifemoral graft resulting in fatality and one axillobifemoral bypass performed for initial presentation with endograft occlusion, followed by endograft explantation and aortic stump creation for the rupture with successful survival but with limb loss ( Table II ). 3 , 4 TEVAR to seal the entry tear in the proximal thoracic aorta as the first step, followed by complete control of impulse in the false lumen proximal to the EVAR with aortic banding, such as was undertaken for patient 1, was a more successful strategy, with complete resolution of the pathology. The second step of exploratory laparotomy was necessary as demonsrated by continued false lumen pulsatility on aortography after TEVAR and confirmed on exposure of the infrarenal aorta, indicating that exclusion of the entry tear did not adequately obliterate sac perfusion, likely due to fenestrations within the paravisceral aorta.…”

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

“…These 12 cases are summarized in Table 1. [5][6][7][8][9][10][11][12][13][14][15] The etiology of TBAD in patients with abdominal EVAR remains unknown. We hypothesize that our case was a primary TBAD, with a high-pressured false lumen compressing and collapsing the abdominal aortic stent graft.…”

“…Previously reported successful repair strategies include axillofemoral bypass, 9 , 11 , 15 open abdominal aortic repair, 9 , 15 and TEVAR of the proximal tear. 6 , 7 , 10 , 12 , 15 The endovascular treatment of abdominal endograft collapse, generally with an aortic balloon and/or cuff, is a viable approach. 6 , 7 In our case, an aortic cuff was placed just below the level of the renal arteries.…”

“…A consensus on treatment strategies for abdominal EVAR collapse has not been established. Previously reported successful repair strategies include axillofemoral bypass, 9 , 11 , 15 open abdominal aortic repair, 9 , 15 and TEVAR of the proximal tear. 6 , 7 , 10 , 12 , 15 The endovascular treatment of abdominal endograft collapse, generally with an aortic balloon and/or cuff, is a viable approach.…”

Sudden endograft collapse due to type B aortic dissection after open conversion of endovascular aortic repair

“…Furthermore, early mortality due to the necrosis of the visceral organs occurred in 2 of the 5 patients who underwent EAB [ 4 ]. Lower-extremity amputation due to intraoperative rupture was performed in 1 patient [ 3 ]. Overall, mortality related to endograft collapse due to TBAD was as high as 42% (5/12).…”