2019 Volume 28 Issue 5 Pages 377-381
We encountered a woman in her 70s who developed wrapping sac enlargement and rupture 14 years after vascular graft replacement for an abdominal aortic aneurysm (AAA). She underwent replacement of an AAA with a straight knitted Dacron graft (12 mm) at 62 years of age and replacement of the ascending aorta owing to Stanford type A acute aortic dissection at 74 years of age. She was transferred to our hospital with a sudden onset of back pain and lumbago. Contrast enhanced computed tomography (CT) revealed the presence of contrast medium between the graft wall and aneurysm sac. Selective angiogram of the bilateral internal iliac and 5th lumbar arteries did not show inflow vessels. The wrapping aneurysm sac rapidly enlarged. An early open repair was scheduled; however, she developed shock suddenly on the 7th hospital day. CT revealed a huge hematoma in the retroperitoneal space. An emergency laparotomy was performed for a ruptured AAA. The aneurysm sac was opened and contained fresh thrombus. The rupture site was recognized in the upper and left side parts of the aneurysm sac. The proximal and distal anastomotic sites were intact. There was pulsatile bleeding from an orifice thought to be a lumbar artery in the lower and left side parts of the aneurysm sac. The orifice was then suture-ligated with 4/0 polypropylene to achieve hemostasis, and the sac was closed. We speculated that resembling type II endoleak was caused by temporary coagulopathy during the perioperative period of Stanford type A acute aortic dissection and the formation of longitudinal vascular network induced by reperfusion of the occluded intercostal artery due to false lumen retrograde blood flow. Resembling type II endoleak can occur even after vascular graft replacement for an AAA irrespective of the time after surgery.
