Parallel grafting in ruptured aortic aneurysms with previous open infrarenal surgical repair

Abstract

Introduction: Although parallel graft endovascular aortic repair (pg-EVAR) was initially described as a rescue technique for endovascular aneurysm repairs that unintentionally excluded visceral branches, its use has expanded to include endovascular repairs of paravisceral and thoracoabdominal aneurysms. However, there is limited literature on utilization in emergency repair of ruptured aortic aneurysms which previously underwent elective open repair. Case 1: A 73-year-old man with a remote history of an open AAA repair with a tube graft presented as a transfer with two weeks of worsening left chest pain and was found to have a 6–7 cm contained rupture of a type III thoracoabdominal aortic aneurysm on computed tomography (CT). Due to his anatomy, previous repair, and comorbidities, endovascular repair was preferred over a redo open approach. He was taken for an emergent endovascular repair – a planned sandwich graft with the proximal seal in the mid thoracic aorta and the distal seal in the infrarenal aortic graft. The stenotic celiac artery was nearly occluded, so visceral stents were placed into the superior mesenteric and bilateral renal arteries. His hospital course was complicated by acute kidney injury, deconditioning, and failure to thrive. CT on postoperative day 44 showed a technically successful pg-EVAR with no evidence of endoleak. Case 2: A 69-year-old woman who recently underwent an open AAA repair at an outside facility developed nausea, vomiting, abdominal pain and down-trending hemoglobin while hospitalized for workup of a new coagulopathy. She was found to have a contained rupture of a proximal anastomotic pseudoaneurysm. Due to her recent repair and current medical state, she was brought to the hybrid suite for emergent endovascular repair. The location of the rupture required entire visceral segment coverage, so a pg-EVAR with spinal drainage was planned. Her celiac, superior mesenteric, and left renal arteries were preserved with stents. Her postoperative course was complicated by a hematoma with persistent rebleeding at her brachial access site which resolved following the placement of a covered stent. CT on postoperative day 16 showed a technically successful pg-EVAR with no evidence of endoleak. Discussion: Many patients remain ineligible for conventional EVAR due to anatomic variations and supra-renal aneurysmal disease. Customized branched or fenestrated endografts have been developed to overcome these limitations. However, production time requires weeks, and grafts with greater than two fenestrations are not commercially available in the United States. Because they use readily available devices, parallel graft repairs may be beneficial when urgent repair is needed. There remains a paucity of data on their usage in emergency repairs of aortic aneurysms, particularly in aneurysms that had been previously repaired surgically. The technical success in the two cases detailed here suggest that parallel graft techniques can be used to expeditiously salvage complex emergency aneurysms with successful sealing of parallel grafts into a previous infrarenal aortic graft.