The good, the bad and the ugly: the tale of an ever-growing aneurysm
DOI:
https://doi.org/10.48750/acv.685Abstract
Background: Aneurysmal sac growth is a major concern after endovascular aortic repair (EVAR) and the main reason for reintervention. Despite timely diagnosis and intervention, some cases of persistent sac growth warrant further investigation, namely for less frequent etiologies.
Report: We report the case of a 68-year-old male patient referred to the Vascular Surgery outpatient clinic due to an asymptomatic 71mm infrarenal abdominal aortic aneurysm. He has a history of heavy smoking habits, severe chronic obstructive pulmonary disease and a previous prostatectomy and local radiotherapy. Due to favorable anatomy and a high surgical risk for open repair, he underwent an aorto-bi-iliac EVAR in 2019. One year follow-up showed no endoleaks nor sac growth. In 2024, due to a significant sac diameter growth to 91mm, an urgent CT angiogram showed loss of proximal sealing and type II endoleak. Based on these findings, a custom-made fenestrated cuff was designed and implanted. Despite adequate sealing, with no evidence of target vessel complications, the patient was admitted in the emergency room 5 months after the reintervention with de novo abdominal and lumbar pain along with frank leukocytosis and an increase in C-reactive protein levels. Urgent CT angiography showed a 105mm diameter sac and periaortic densification, with apparent type II endoleak. The patient was put empirically on meropenem and linezolide. An urgent open conversion was performed with graft preservation and thrombus removal, and sac wrapping. Mycoplasma hominis was isolated from the aneurysm sac and thrombus and the patient was discharged on levofloxacin and doxycycline. One month follow-up showed no signs of recurrence.
Discussion: In the absence of clear sources of endoleak, infection may be the cause for over 20% of occult sac growth. In frail patients such as this case, sac evacuation and wrapping may be an alternative approach to graft explantation.
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References
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