Percutaneous embolization of a ruptured mycotic visceral aortic aneurysm stump hemorrhage

Abstract

Introduction and Objective Managing infected endovascular aortic stent grafts is difficult and often has morbid consequences. We report a complicated case of endovascular aortic stent graft infection treated through complex surgical and endovascular management. A standard attempt at open surgical correction was made, however, due to the complex nature of the patient's condition; much of the treatment accomplishedvia endovascular techniques for ultimate resolution. Case Report Graphical AbstractA) CTA maximum intensity projection after initial surgical repair demonstrating an axillary-femoral and femoral-femoral bypass creation (star), distal aortic and bilateral artery ligation (asterisks). B) Sagittal abdominal CTA 2 weeks after initial surgery demonstrating contrast extravasation from the aortic stump (arrow). View Large Image Figure Viewer Download Hi-res image Graphical AbstractA) Posterior projection of a volume rendered CTA after the second surgical repair demonstrating distal thoracic aorta ligation (open arrow), previous ligations (asterisks), bypass grafts from the distal thoracic aorta to the SMA (white arrow), splenic artery (open arrowhead), and left renal artery (white arrowhead). B) Sagittal abdominal CTA demonstrating recurrent hemorrhage in the visceral aorta (arrow), with themultiple ligations (asterisks) of the aorta and SMA, as well as the celiac bypass (arrowhead). View Large Image Figure Viewer Download Hi-res image Graphical AbstractA) Oblique image of the aortic stump access using an 18-gauge Hawkins needle (Cook, Bloomington, IN) (white arrowheads) shows inflow at the celiac ostium as a contrast void (white circle), opacification of the replaced right hepatic (black arrow), right renal artery (black arrowhead), and visceral aorta with extravasation of contrast (white arrow). B) SOS 2 catheter (Cook, Bloomington, IN) selection of the celiac artery (white arrow head) with retrograde flow in to the aortic lumen (white circle), inflow from the splenic artery stump bypass (black arrowhead), and antegrade flow into the common hepatic artery (black arrow). View Large Image Figure Viewer Download Hi-res image Graphical AbstractThe ostia of the celiac artery, right renal artery, and direct aortic origin right hepatic celiacartery origin were embolized using multiple techniques. A) A 0.24 microcatheter (white arrowhead) was advanced into the splenic artery and used to place an Amplatz IV (6 × 11mm) (St. Jude Medical, St. Paul, MN) (black arrowhead) into the ostium of the celiac artery to exclude the aortic stump but preserve hepatic arterial supply. Direction of blood flow from the splenic bypass towards the celiac ostium and into the common hepatic artery is demarcated with open arrows. B) The replaced right hepatic artery was embolized with multiple 0.018 6mm and 4mm detachable coils (Boston Scientific S Interlock, Marlboro, MA) (arrow). C) The visceral aortic lumen and right renal artery were embolized with 0.035 and 0.018 detachable coils (Boston Scientific S Interlock, Marlboro, MA), a 0.035 Benson wire with removed mandrel (Cook,Bloomington, IN) and n-BCA glue (TruFill Johnson and Johnson, Miami, FL). The aortic access track was then closed with an 8mm Amplatz plug and n-BCA glue (arrowhead). View Large Image Figure Viewer Download Hi-res image Graphical AbstractA) 3-year post-operative follow up 3D rendered image showing patents bypasses to the SMA (white arrow), splenic artery (open arrowhead), and left renal artery (white arrowhead), stable ligation of the distal thoracic aorta and embolized visceral abdominal aorta. B) 3-year post-operative sagittal CT showing absence of perfusion to the visceral aortic (arrow). View Large Image Figure Viewer Download Hi-res image Discussion Complex aortic surgery is challenging especially in the presence of recurrent infection. This case was a unique situation in which a less invasive endovascular correction was successful for a patient with multiple recent aortic surgeries in which perioperative mortality for any additional surgeries was likely. Managing infected endovascular aortic stent grafts is difficult and often has morbid consequences. We report a complicated case of endovascular aortic stent graft infection treated through complex surgical and endovascular management. A standard attempt at open surgical correction was made, however, due to the complex nature of the patient's condition; much of the treatment accomplishedvia endovascular techniques for ultimate resolution. Complex aortic surgery is challenging especially in the presence of recurrent infection. This case was a unique situation in which a less invasive endovascular correction was successful for a patient with multiple recent aortic surgeries in which perioperative mortality for any additional surgeries was likely.