Aorta
AAA

When previous FEVAR complicates the picture

A 72-year-old man with a history of fenestrated endovascular aortic repair (FEVAR) presents with abdominal symptoms and multiple comorbidities.

What initially appears to be a non-specific clinical picture soon evolves into a complex vascular challenge, where previous aortic repair plays a pivotal role in determining the treatment strategy.

Faced with several possible therapeutic options, what would you choose?

Wassim Mansour
Wassim Mansour
Sapienza Università di Roma - Policlinico Umberto I di Roma
Associate Professor in Vascular Surgery - Vascular Surgeon
Part I - Case presentation

Clinical presentation

A 72-year-old man with significant cardiovascular comorbidities presented with non-specific abdominal symptoms in the context of previous complex aortic repair.

Medical history:
 

  • Systemic hypertension
  • Chronic ischaemic cardiomyopathy
  • Atrial fibrillation
  • Mild renal insufficiency
  • Myelodysplasia

Previous aortic intervention:
 

  • FEVAR performed in 2023
  • including four bridging stents: for SMA + CT + 1 RRA + 2 LRA (scallop for CT)

Recent clinical presentation:
 

Assessment 20 days earlier for abdominal constipation and asthenia
 

Powered by Quiz Maker

 

Part two

Therapeutic strategy

The discovery of a spontaneous pseudoaneurysm raised the suspicion of an infectious process, requiring further investigation and careful monitoring.

Microbiological assessment:
 

  • Blood cultures and urine cultures performed
  • No infectious agent identified

Management approach:
 

  • Prophylactic antibiotic therapy started
  • Continuous surveillance of vital parameters and clinical status

Intervention programmation

Coeliac Pseudo aneurysm treatment in emergency - Figure 1
Previous fEVAR

Many technical options have been discussed:

Coeliac Pseudo aneurysm treatment in emergency - Figure 2
OPTION 1: TEVAR extension with CT coverage
Coeliac Pseudo aneurysm treatment in emergency - Figure 3
OPTION 2: PMEG with 5 fenestrations
Coeliac Pseudo aneurysm treatment in emergency - Figure 4
OPTION 3: bEVAR

Clinical deterioration

48 hours later, the patient's condition suddenly worsened:

  • Acute onset of abdominal pain
  • Severe hypotension (70/40 mmHg)
  • Acute anaemia

Diagnosis:
 

Rupture of the pseudoaneurysm leading to haemodynamic instability

Programmation during emergent setting

Coeliac Pseudo aneurysm treatment in emergency - Figure 5

Procedure

PMEG with 2 fenestrations for CT + SMA to extend above and exclude the aneurysm with sufficient distal sealing in the previous fEVAR.

Following the emergency procedure, the patient was closely monitored in the intensive care unit.

Post-operative care:
 

  • 24-hour admission to the ICU
  • Close clinical surveillance

Biological assessment:
 

  • Transient increase in serum creatinine to 2.3 mg/dL
  • No fever reported
  • Two blood cultures remained negative

Further investigation:
 

PET-CT scan scheduled to further assess the underlying aetiology

CT post-operative

Late post-operative course

After an initially stable recovery, the patient presented 27 days later with new clinical signs raising concern for a potential underlying complication:

  • Lumbar pain
  • Fever
  • Asthenia

Microbiological assessment and ongoing management

Microbiological investigations:
 

  • Blood cultures remained negative
  • Collection drainage was sterile

Therapeutic management:
 

Antibiotic therapy initiated with dalbavancin

Coeliac Pseudo aneurysm treatment in emergency - Figure 6

Further clinical evolution to be continued...