2020 Volume 29 Issue 6 Pages 405-410
A 70-year-old male was admitted with acute left-sided lumbago after hemodialysis. He underwent endovascular aneurysm repair (EVAR: ENDURANT II, Medtronic, Santa Rosa, CA, USA) approximately five years previously for an infrarenal abdominal aortic aneurysm (AAA) of 71×78 mm in size followed by two additional endovascular treatments by coil embolization for progressive sac enlargement due to a residual type II endoleak. However, AAA expanded and, thus, impending rupture was suspected at that time. Urgent open conversion was performed and dissection around AAA was challenging due to dense adhesions. Since the proximal neck and bilateral common iliac arteries were tightly tied down with a tape tourniquet to prevent bleeding from an occulted type I endoleak, bleeding from the landing zone was not detected. Bleeding from two lumbar arteries was readily sutured with a bloodless surgical field following the incision of AAA and removal of a hematoma within AAA. The inferior mesenteric artery was easily detected and also ligated outside the aneurysmal wall. Extraction of the EVAR device was not required and the aneurysmal wall was resected and tightly sutured as much as possible. Proximal and distal banding was performed to prevent further type I endoleaks. Since intraoperative blood salvage was performed, the patient did not receive blood transfusion. Although the approach to each patient requiring delayed conversion must be individualized, the complete preservation of endografts is possible, similar to the present case. Surgery was performed without any hemodynamic compromise and the postoperative clinical course was good. We herein report a surgical case of the urgent open conversion for the impending rupture of AAA due to a type II endoleak following EVAR and additional coil embolization twice. We also reviewed and summarized the strategies from previous domestic case reports of this complex condition.
