Successful Endovascular Management of Intraoperative Graft Limb Occlusion and Iliac Artery Rupture Occurred during Endovascular Abdominal Aortic Aneurysm Repair
A 75-year-old man visited the emergency room with anemia and dizziness. He was taking warfarin for deep vein thrombosis and had a hemoglobin level of 4.5 g/dL. The prothrombin time (international normalized ratio) was 6.28. He had undergone low anterior resection and partial bladder resection with adjuvant chemotherapy to treat sigmoid colon cancer 3 years earlier. He had also undergone incisional ventral hernia repair. He did not show hematochezia, melena, or abdominal tenderness/rebound tenderness. The anemia and the prolongation of the prothrombin time were easily corrected; thus, continuous bleeding was not suspected. Nevertheless, in order to rule out gastrointestinal bleeding as a cause of the severe anemia, abdominal computed tomography (CT) was performed. However, there was no evidence of intra-abdominal bleeding. Instead, a 55-mm abdominal aortic aneurysm with eccentric bulging combined with a right common iliac artery aneurysm (). The aneurysm size increased by 10 mm compared with the size 2 years previously. Because severe intra-abdominal adhesion and wound problems after laparotomy were expected, endovascular aortic aneurysm repair (EVAR) was recommended instead of open surgery. EVAR was started with the deployment of a bifurcated main body using an aortic stent graft of 30×30×40 mm and an inner bare stent 32×32×50 mm in size (S&G Biotech Inc., Seongnam, Korea). Subsequent extension of the right graft limb was performed uneventfully using two covered stents (12×12×80 mm and 12×12×60 mm) to exclude the right common iliac artery aneurysm. Dreadful complications occurred during the last procedure of the left graft limb extension. After the selection of the left graft limb and the guide wire exchange to a Lunderquist stiff wire (Cook Inc., Bloomington, IN, USA), a 16F introducer sheath was inserted for the delivery of a limb extension graft, but the tip of the sheath perforated the left proximal external iliac artery during the advancement of the sheath (). Sheath-pushing against the tortuous iliac artery caused the guide wire to slip back into the sheath, and the dilator tip punctured the arterial wall. Although the extension of the left graft limb was scheduled to end at the distal common iliac artery, the extension was promptly determined to be lengthened to the external iliac artery to cover the perforated site. The left graft limb of the main body was reselected, and a stent graft of 12×12×100 mm was deployed. A sheath angiography showed no further extravasation. However, subsequent aortography showed an occlusion of the left graft limb, and acute thrombosis was suspected (). A prompt balloon thrombectomy was attempted after the left superficial and deep femoral arteries were clamped to prevent distal embolization. A 6F balloon catheter was advanced through the occlusion and withdrawn carefully not to cause disjunction of the overlapped stent grafts. Fresh thrombus was successfully removed, and the graft flows became excellent without any endoleak upon the completion of angiography (). The patient was extubated and transferred to the general ward on the following day. He was discharged on the fifth postoperative day. Postoperative follow-up CT scan showed no endoleak (). At the 3-month follow-up, the patient was doing well without any symptoms like buttock claudication.