1. Rupture of proximal anastomosis after AAA open repair: EVAR with bilateral renal chimney as bailout procedure
Arne Schwindt1, Francesca Fratesi2,
Andrea Stella2, Giovanni Torsello1
1: Vascular Surgery, St. Franziskus-Hospital, Münster
2: Vascular Surgery, Policlinico Sant'Orsola-Malpighi, Bologna 1

2. Case Presentation 63 yo, M Risk factors: Coronary artery disease
Dyslipidemia
Hypertension
Diabetes Mellitus (insulin dependent)

3. Case Presentation 2008, February: EVAR for AAA 2011, September:
Type I endoleak Aorto-bisiliac Dacron prosthesis
2011, October:
- Re-laparotomy for proximal anastomosis contained rupture
At 3th post-op day:
TEVAR for Aortic dissection
At 1 week:
Referral to our Center for proximal anastomosis contained re-rupture

4. Pre-operative Assessment
-No infra-renal neck
-Perirenal diameter: 38mm
-Distance SMA-prothesis: 7,8 cm
-Patient unfit for Open repair
-Juxtarenal aortic wall not valid for suture

5. Intra-operative
- Placement of 7Fx90cm sheaths in both renal arteries (bilateral brachial access)
- Marking the SMA with 5F Cobra catheter.
- Marking the neobifurcation with glide-wire (left femoral access)
- Introducing 44x100mm Valiant- Medtronic thoracic endograft (right femoral access)

6. Intra-operative Release of the endograft below the ostium of SMA
Compressing the endograft during release down to 8cm in length to land in the main body of the Dacron- prothesis
Chimney stent-graft for both renal arteries (Advanta 7x38 mm right, Advanta 7x59mm left)

7. Intra-operative
- Implant of PalmazXL 20x34mm in the distal landing zone to avoid Type I EL

8. Emergent repair (direct suture)
Post-operative
36 hours post-operative:
- Hematemesis
CT-scan showed:
Exlusion of rupture with patency of both chimney stent-graft
-Aorto-jejunal fistula
Emergent repair (direct suture)

9. Post-operative - Discharged @ 16th postoperative day
- No further complications were observed

10. 6 months follow-up At CT scan: Patency of both chimney grafts
No EndoLeaks

11. Conclusions
But... Vertebral Erosion!!!

12. Literature
- Chimney-graft can be a useful tool in the emergency setting, specially in patients not eligible for standard open or endovascular repair, with good perioperative and short term results (1)
- Secondary Aorto-enteric fistula is a rare and high-risk condition after AAA open repair (incidence < 1%) and it must be suspected if a gastro inetstinal bleeding occurs in a patient treated with AAA open repair (2)
- Vertebral erosion and infection can be associated with contained rupture of AAA due to the mass effect of the aneurism sac itself (3)
1: Tolenaar JL, et al. Ann Vasc Surg 2012, articl in press
2: Bergqvist D et al. Eur J Vasc Endovasc Surg , 31-42
3: Yamamoto H et al. Ann Vasc Surg 2010; 24: 824e1-824e5

13. Conclusions
- Rupture of proximal anastomosis after AAA open repair can be a life threatening complication
- Chimney graft is a safe and feasible bailout technique to use in emergent settings
- Relapsing contained rupture can lead to rare complication such as aorto-enteric fistula and vertebral erosion

14. Grazie!
Thank You!
Vielen Dank!
Merci Beaucoup!