2021 Ischemic Duodenal Ulceration After Thoracic Endovascular Aortic Repair (TEVAR)

Abstract

INTRODUCTION: Ischemia is a rare cause of duodenal ulcers due to the redundant blood supply in the duodenum. Aortic surgery is a known, but rare, risk factor for mesenteric ischemia. Endovascular aortic repair is an increasingly common alternative to open surgery for select patients with aortic aneurysms, however post-procedural complications including endoleaks and graft migration can occur. Less commonly reported complications include bowel ischemia, with only a handful of reports detailing duodenal ulceration in the current literature. Here we present a case of ischemic duodenal ulceration following thoracic endovascular aortic repair (TEVAR). CASE DESCRIPTION/METHODS: An 82-year-old male on dual-antiplatelet therapy presented with complaints of lightheadedness, dyspnea, and melena. He had been discharged to skilled nursing three days earlier following thoracic endovascular aortic repair (TEVAR) for DeBakey type III aortic dissection distal to the left subclavian artery. His recovery was complicated by endovascular leak at the left subclavian artery, left renal artery dissection, and thrombosis of the superior mesenteric artery (SMA), which were treated with coiling and stenting of the left renal artery and SMA. Hemoglobin upon hospital return was 6.7 g/dL compared to 8.3 g/dL on initial discharge. Esophagogastroduodenoscopy revealed a large, near-circumferential Forrest IIc ulcer in the duodenum with concern for underlying ischemic etiology. Computed tomography angiography (CTA) of the chest and abdomen revealed a duodenal ulcer with associated mural thickening and fat stranding. CTA reconfiguration identified stenosis at the bifurcation of the common hepatic artery and stenosis of the celiac artery compared to post-TEVAR CTA images. These findings were confirmed with celiac angiography and repaired using drug coated balloon catheter percutaneous transluminal angioplasty to the common hepatic artery and balloon expandable stenting to the celiac artery. The patient’s hemoglobin stabilized post-operatively and he had complete symptom resolution. DISCUSSION: Upper intestinal ischemia is a rare but important cause of duodenal ulceration and hemorrhage following TEVAR, as demonstrated in this case. Bowel ischemia from TEVAR is more commonly seen when the distal aspect of the graft has celiac artery involvement. Early recognition of ischemic duodenal ulceration after TEVAR is of significant clinical importance, as treatment differs from other etiologies of duodenitis and early intervention lowers morbidity.