Abstracts
Para-anastomotic aneurysms are either true aneurysms or pseudoaneurysms. The latter tend to be asymptomatic until rupture. Para-anastomotic aneurysms should be approached surgically, despite the high morbidity and mortality associated with their treatment. This report describes the case of a 68-year-old woman who presented with a para-anastomotic pseudoaneurysm secondary to infrarenal aortic aneurysmectomy. We chose to use an endovascular approach, and results were good. Endovascular techniques are increasingly becoming the method of choice in the treatment of anastomotic pseudoaneurysms.
pseudoaneurysm; aorta; postoperative complications; aortic aneurysm; endovascular procedures
Os aneurismas para-anastomóticos de aorta podem ser verdadeiros ou pseudoaneurismas. Estes últimos tendem a ser assintomáticos até a ruptura. Devem ser tratados cirurgicamente, apesar da alta morbimortalidade em sua abordagem. Este relato descreve o caso de uma paciente do sexo feminino, 68 anos, com quadro de pseudoaneurisma para-anastomótico pós-aneurismectomia de aorta infrarrenal. Optou-se por correção endovascular, com bons resultados. As técnicas endovasculares vêm se estabelecendo como o método de escolha no tratamento dos pseudoaneurismas anastomóticos.
pseudoaneurisma; aorta; complicações pós-operatórias; aneurisma aórtico; procedimentos endovasculares
INTRODUCTION
Para-anastomotic aneurysms may be either true aneurysms or pseudoaneurysms. Its incidence reaches 10% eight to nine years after aneurysmectomy. Pseudoaneurysms tend to be asymptomatic until rupture. They may occur at any time after operation, but its incidence increases with follow-up time. They should be treated surgically even when asymptomatic, because mortality reaches 61% in the case of conservative treatment. However, open reoperation is technically difficult, and its morbidity and mortality rates are high.
CASE REPORT
This study describes the case of a 68-year-old woman with hypertension and depression under control, who denied smoking or diabetes. Previous surgeries: appendectomy, perineoplasty, cystopexy, hysterectomy, varicectomy, knee arthroplasty and surgical repair of abdominal aorta aneurysm. Eight years earlier she had undergone infrarenal aortic aneurysmectomy and aortoaortic bypass using a 14-mm Dacron graft. Immediate postoperative recovery was good.
A year and a half after the procedure, a CT angiogram (angio-CT) showed no evidence of abnormalities (Figure 1), and an arterial duplex scan of the lower limbs to investigate popliteal artery aneurysm did not show any changes.
Angiotomografia - prótese de Dácron com anastomose aortoaórtica infrarrenal sem pseudoaneurisma - perceber presença de colo infrarrenal.
Four years after operation, angio-CT showed Dacron graft dilatation (25 mm diameter), without pseudoaneurysm or leaking. Changes remained stable in the sixth year, and the patient remained asymptomatic.
Eight years after operation she had sporadic abdominal cramps. Ultrasound (US) scanning revealed the presence of biliary sludge, and angio-CT showed a distal thrombosed para-anastomotic pseudoaneurysm measuring 6.0 × 5.0 cm (Figures 2 and 3). An endovascular approach under general anesthesia was selected, and the procedure consisted of dissection of femoral arteries bilaterally, implant of bifurcated steel and Dacron graft (body of graft measuring 26 mm × 82 mm) and extending to the distal third of the common iliac arteries, with a diameter of 12 mm (Figure 4). Postoperative progression was good and she was discharged on the second day after operation. She remains under outpatient follow-up, with no complaints and asymptomatic three years after operation.
Angiotomografia: Plano sagital com pseudoaneu risma trombosado de 65 mm em anastomose distal.
DISCUSSION
Of all the complications of aortoiliac bypass grafts, anastomotic pseudoaneurysm is the
most common late complication. The following complications may be listed: pseudoaneurysm
(3%), thrombosis (2%), enteric erosion/fistula (1.6%), graft infection (1.3%),
anastomotic hemorrhage (1.3%), colon ischemia (0.7%) and atheroembolism (0.3%)11. Hallett JW Jr, Marshall DM, Petterson TM, et al. Graft-related
complications after abdominal aortic aneurysm repair: reassurance from a 36-year
population-based experience. J Vasc Surg. 1997;25:277-284.
http://dx.doi.org/10.1016/S0741-5214(97)70349-5
http://dx.doi.org/10.1016/S0741-5214(97)...
. They occur at a mean 10 to 12 years after operation, affect the distal
anastomosis primarily22. Biancari F, Ylýnen K, Anttila V, et al. Durability of open repair of
infrarenal abdominal aortic aneurysm: a 15-year follow-up study. J Vasc Surg.
2002;35:87-93. PMid:11802137., and are asymptomatic until rupture, with a tragic outcome for the patient and
the medical team.
The continuous degeneration of the artery wall after graft implantation may weaken the suture between the artery and the prosthesis along the years, which may give origin to the pseudoaneurysm.
Szilagyi reported the occurrence of anastomotic aneurysms in 0.2% of the aortic
anastomosis, 1.2% of the iliac anastomosis, and in 3% of the femoral anastomosis three
years after operation33. Szilagyi DE, Hageman JH, Smith RF, Elliott JP. Spinal cord damage in
surgery of the abdominal aorta. Surgery. 1978;83:38-56. PMid:619471.. Edwards reported and incidence of 1% of anastomotic pseudoaneurysm eight years
after operation, and 20% 15 years later, with detection at a mean 12 years after
operation44. Edwards JM, Teefey SA, Zierler RE, Kohler TR.
Intraabdominalparaanastomotic aneurysms after aortic bypass grafting. J Vasc Surg.
1992;15:344-350. http://dx.doi.org/10.1016/0741-5214(92)90256-8
http://dx.doi.org/10.1016/0741-5214(92)9...
.
Imaging follow-up (angio-CT and MRA) for three to five years after operation is
recommended to detect new aneurysms or pseudoaneurysms under formation, and therefore
avoid rupture55. Hertzer NR, Mascha EJ, Karafa MT, et al. Open infrarenal abdominal
aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998. J Vasc
Surg. 2002;35:1145-1154. PMid:12042724.
http://dx.doi.org/10.1067/mva.2002.123686
http://dx.doi.org/10.1067/mva.2002.12368...
.
Open reoperation is technically difficult because of adhesions and fibrosis, and its
mortality rate is 5% to 17% when elective, and 24% to 88% when there is rupture66. Pearce BJ, Baldwin Z, Bassiouny H, Gewertz BL, McKinsey JF.
Endovascular solutions to complications of open aortic repair. Vasc Endovascular
Surg. 2005;39(3):221-8. PMid:15920650.
http://dx.doi.org/10.1177/153857440503900302
http://dx.doi.org/10.1177/15385744050390...
. Endovascular repair has a mortality rate of about 3.8%77. Sachdev U, Baril DT, Morrissey NJ, et al. Endovascular repair of
para-anastomotic aortic aneurysms. J Vasc Surg. 2007;46(4):636-41. PMid:17764881.
http://dx.doi.org/10.1016/j.jvs.2007.05.032
http://dx.doi.org/10.1016/j.jvs.2007.05....
.
The endovascular approach has gained importance, with successful results in several case
series66. Pearce BJ, Baldwin Z, Bassiouny H, Gewertz BL, McKinsey JF.
Endovascular solutions to complications of open aortic repair. Vasc Endovascular
Surg. 2005;39(3):221-8. PMid:15920650.
http://dx.doi.org/10.1177/153857440503900302
http://dx.doi.org/10.1177/15385744050390...
7. Sachdev U, Baril DT, Morrissey NJ, et al. Endovascular repair of
para-anastomotic aortic aneurysms. J Vasc Surg. 2007;46(4):636-41. PMid:17764881.
http://dx.doi.org/10.1016/j.jvs.2007.05.032
http://dx.doi.org/10.1016/j.jvs.2007.05....
8. Mitchell JH, Dougherty KG, Strickman NE, Mortazavi A, Krajcer Z.
Endovascular repair of paraanastomotic aneurysms after aortic reconstruction. Tex
Heart Inst J. 2007;34(2):148-53. PMid:17622359 PMCid:1894696.
9. Ten Bosch JA, Waasdorp EJ, De Vries JP, Moll FL, Teijink JA, Van
Herwaarden JA. The durability of endovascular repair of para-anastomotic aneurysms
after previous open aortic reconstruction. J Vasc Surg. 2011;54(6):1571-8. Epub 2011
Sep 23. PMid:21944919. http://dx.doi.org/10.1016/j.jvs.2011.04.072
http://dx.doi.org/10.1016/j.jvs.2011.04....
-
1010. Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Caronno R, Castelli P.
Endovascular treatment for para-anastomotic abdominal aortic and iliac aneurysms
following aortic surgery. J Cardiovasc Surg. 2007 Dec;48(6):711-7.. It reduces morbidity and mortality, particularly in high-risk surgical
patients. Its initial technical success is about 98% at the time of implantation, and it
reduces perioperative mortality to about 3.8%77. Sachdev U, Baril DT, Morrissey NJ, et al. Endovascular repair of
para-anastomotic aortic aneurysms. J Vasc Surg. 2007;46(4):636-41. PMid:17764881.
http://dx.doi.org/10.1016/j.jvs.2007.05.032
http://dx.doi.org/10.1016/j.jvs.2007.05....
,
99. Ten Bosch JA, Waasdorp EJ, De Vries JP, Moll FL, Teijink JA, Van
Herwaarden JA. The durability of endovascular repair of para-anastomotic aneurysms
after previous open aortic reconstruction. J Vasc Surg. 2011;54(6):1571-8. Epub 2011
Sep 23. PMid:21944919. http://dx.doi.org/10.1016/j.jvs.2011.04.072
http://dx.doi.org/10.1016/j.jvs.2011.04....
. Despite the complications associated with endoprostheses, such as endoleaks
(type II are the most common), thrombosis, migration, rupture, structural failures and
infections, short- and long-term follow-up shows lower complication rates than open
surgery. This suggests that the endovascular approach may definitely become the method
of choice for the treatment of anastomotic pseudoaneurysms66. Pearce BJ, Baldwin Z, Bassiouny H, Gewertz BL, McKinsey JF.
Endovascular solutions to complications of open aortic repair. Vasc Endovascular
Surg. 2005;39(3):221-8. PMid:15920650.
http://dx.doi.org/10.1177/153857440503900302
http://dx.doi.org/10.1177/15385744050390...
7. Sachdev U, Baril DT, Morrissey NJ, et al. Endovascular repair of
para-anastomotic aortic aneurysms. J Vasc Surg. 2007;46(4):636-41. PMid:17764881.
http://dx.doi.org/10.1016/j.jvs.2007.05.032
http://dx.doi.org/10.1016/j.jvs.2007.05....
8. Mitchell JH, Dougherty KG, Strickman NE, Mortazavi A, Krajcer Z.
Endovascular repair of paraanastomotic aneurysms after aortic reconstruction. Tex
Heart Inst J. 2007;34(2):148-53. PMid:17622359 PMCid:1894696.
-
99. Ten Bosch JA, Waasdorp EJ, De Vries JP, Moll FL, Teijink JA, Van
Herwaarden JA. The durability of endovascular repair of para-anastomotic aneurysms
after previous open aortic reconstruction. J Vasc Surg. 2011;54(6):1571-8. Epub 2011
Sep 23. PMid:21944919. http://dx.doi.org/10.1016/j.jvs.2011.04.072
http://dx.doi.org/10.1016/j.jvs.2011.04....
.
In the case reported here, the patient underwent follow-up using imaging tests every two years, and a pseudoaneurysm of the distal aortic anastomosis was detected eight years later. The patient had discrete abdominal pain that radiated to the dorsal region. Abdominal ultrasound detected gallstone, and the hypothesis of pain of biliary origin was raised.
Radiological follow-up showed an increase in the diameter of the pseudoaneurysm, and the endovascular repair was chosen. Abdominal pain resolved completely and the abdominal mass regressed. After three years of follow-up, the patient remains asymptomatic and imaging control has not detected any changes to this moment.
CONCLUSION
The chance of developing a para-anastomotic aneurysm or pseudoaneurysm increases and may reach 20% 15 years after operation, which increases the chances of rupture significantly. Most cases have an asymptomatic progression until rupture, and the outcome is tragic.
Para-anastomotic aneurysms are the most common late complication of the conventional repair of abdominal aorta aneurysm. Adhesions and inflammation caused by the aneurysm and by the previous surgery may complicate surgical access for the correction of this complication, and morbidity and mortality rates are high.
An interesting option, which has shown good short- and middle-term results, as long as the patient's anatomy is favorable, is the endovascular approach, which reduces morbidity and mortality when reoperating this type of late complication of aortic repair.
REFERENCES
-
1Hallett JW Jr, Marshall DM, Petterson TM, et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg. 1997;25:277-284. http://dx.doi.org/10.1016/S0741-5214(97)70349-5
» http://dx.doi.org/10.1016/S0741-5214(97)70349-5 -
2Biancari F, Ylýnen K, Anttila V, et al. Durability of open repair of infrarenal abdominal aortic aneurysm: a 15-year follow-up study. J Vasc Surg. 2002;35:87-93. PMid:11802137.
-
3Szilagyi DE, Hageman JH, Smith RF, Elliott JP. Spinal cord damage in surgery of the abdominal aorta. Surgery. 1978;83:38-56. PMid:619471.
-
4Edwards JM, Teefey SA, Zierler RE, Kohler TR. Intraabdominalparaanastomotic aneurysms after aortic bypass grafting. J Vasc Surg. 1992;15:344-350. http://dx.doi.org/10.1016/0741-5214(92)90256-8
» http://dx.doi.org/10.1016/0741-5214(92)90256-8 -
5Hertzer NR, Mascha EJ, Karafa MT, et al. Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998. J Vasc Surg. 2002;35:1145-1154. PMid:12042724. http://dx.doi.org/10.1067/mva.2002.123686
» http://dx.doi.org/10.1067/mva.2002.123686 -
6Pearce BJ, Baldwin Z, Bassiouny H, Gewertz BL, McKinsey JF. Endovascular solutions to complications of open aortic repair. Vasc Endovascular Surg. 2005;39(3):221-8. PMid:15920650. http://dx.doi.org/10.1177/153857440503900302
» http://dx.doi.org/10.1177/153857440503900302 -
7Sachdev U, Baril DT, Morrissey NJ, et al. Endovascular repair of para-anastomotic aortic aneurysms. J Vasc Surg. 2007;46(4):636-41. PMid:17764881. http://dx.doi.org/10.1016/j.jvs.2007.05.032
» http://dx.doi.org/10.1016/j.jvs.2007.05.032 -
8Mitchell JH, Dougherty KG, Strickman NE, Mortazavi A, Krajcer Z. Endovascular repair of paraanastomotic aneurysms after aortic reconstruction. Tex Heart Inst J. 2007;34(2):148-53. PMid:17622359 PMCid:1894696.
-
9Ten Bosch JA, Waasdorp EJ, De Vries JP, Moll FL, Teijink JA, Van Herwaarden JA. The durability of endovascular repair of para-anastomotic aneurysms after previous open aortic reconstruction. J Vasc Surg. 2011;54(6):1571-8. Epub 2011 Sep 23. PMid:21944919. http://dx.doi.org/10.1016/j.jvs.2011.04.072
» http://dx.doi.org/10.1016/j.jvs.2011.04.072 -
10Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Caronno R, Castelli P. Endovascular treatment for para-anastomotic abdominal aortic and iliac aneurysms following aortic surgery. J Cardiovasc Surg. 2007 Dec;48(6):711-7.
-
Financial support: None
-
* All authors should have read and approved of the final version of the article submitted to J Vasc Bras.
Publication Dates
-
Publication in this collection
June 2013
History
-
Received
16 Feb 2013 -
Accepted
28 Feb 2013