Early periaortic hematoma development after EVAR in the presence of severely calcified and modestly conical-shaped aortic neck: A potential trigger for sudden aneurysm progression toward rupture

Abstract

Objective The aim of this report is to present a singular case of early post-endovascular aneurysm repair abdominal aortic aneurysm rupture and discuss the possible etiopathogenic mechanism promoting the sudden aneurysm progression toward rupture. Methods/Results: An 84-year-old man was submitted to endovascular aneurysm repair via second-generation endograft (Cordis-Incraft Stent-graft) during which, the left occluded common iliac artery was recanalized via balloon-expandable covered-stent-graft (Atrium-Advanta-V12). The aneurysm presented a severely calcified and modestly conical-shaped aortic-neck. The post-operative course was complicated by a broncho pneumonic infiltrate and a CT scan performed two weeks postoperatively accidentally revealed a relatively small hematoma surrounding the aortic wall. No active bleeding, endoleak, or aneurysm increase in diameter was documented. Nevertheless, the patient remained closely monitored. Three days later, he suffered from abdominal aortic aneurysm rupture. A CT scan revealed an arterial wall tear at the neck level. Intra-operatively the reanalyzed common iliac artery was intact and a good endograft-sealing was confirmed. Following this event, small lumbar arteries suture saccotomy was performed. The patient eventually died of multiorgan failure one month later. Conclusions The apparently “self-limiting” post-endovascular aneurysm repair CT-scan finding of periaortic hematoma may have represented a potential trigger for abdominal aortic aneurysm rupture. The possibility of developing undetected aortic lesions during endovascular aneurysm repair, specifically in the presence of potentially “at risk” anatomical conditions, should always be considered.