Managing Complex EVAR Complications: Infection, Fistula, and High-Risk Patients

Initial Presentation and Assessment

• 🚨 A 65-year-old male presented with a massive 18 cm AAA and a Type 1B endoleak, with concerning CT findings including gas in the sac and fluid in the abdomen, suggesting potential rupture or graft infection.
• 🩺 The patient had a complex medical history including extensive cardiac issues (low EF, previous arrests), a history of EVAR 10 years prior, a previous Type 1B endoleak treated with leaving against medical advice, and a right common iliac artery aneurysm.
• 💡 Initial management focused on hemodynamic stabilization, ICU admission, fluid resuscitation, antibiotics, and multidisciplinary consultation with cardiology, electrophysiology, and senior vascular surgeons.

Endovascular Intervention for Stabilization

• 🎯 A staged approach was chosen, beginning with an endovascular intervention to address the Type 1B endoleak and right common iliac artery aneurysm by coiling the hypogastric artery and extending the iliac limb.
• 🛠️ A left femoral pseudoaneurysm was also stented using a covered stent to exclude it.
• 📈 Post-angiogram confirmed resolution of the endoleak and pseudoaneurysm, aiming to temporize the patient's condition and allow for optimization before a more definitive procedure.

Transition to Open Exploration

• ⚠️ Despite initial endovascular success, the patient developed worsening symptoms including high NG tube output, dilated bowel loops, free fluid, and anemia, highly suspicious for an aortic fistula and partial small bowel obstruction (SPBO).
• 🏥 The decision was made to proceed with an open exploration to address the suspected aortic fistula and bowel involvement.
• 🔪 During surgery, 2 liters of purulent fluid were found, with two connections of the aneurysm sac to the bowel identified and excised, followed by primary anastomosis and irrigation of the sac.

Challenges of Infected Graft Management

• 🧩 The team opted to leave the endograft in place, managing the obvious infection with local control and antibiotic irrigation, prioritizing patient survival and quality of life over immediate graft explantation due to severe comorbidities.
• 🦠 Intraoperative cultures grew Candida albicans and Bacteroides, highly virulent organisms that complicated management.
• 📉 Postoperatively, the patient experienced further decompensation, including suspected graft blowout, bleeding, worsening liver and renal function, and gastrointestinal bleeding, requiring multiple interventions.

Retrospective Analysis and Takeaways

• 🔍 In retrospect, while the staged endovascular-then-open approach was deemed appropriate for this critically ill patient, considerations like damage control for the intestinal anastomosis and establishing clear goals of care were highlighted.
• 🤝 The importance of multidisciplinary collaboration and consulting experienced colleagues, even non-surgeons, was emphasized.
• 📌 Long-term surveillance after EVAR is crucial, as complications can arise years post-procedure, and the management of infected aortic grafts remains complex with no single gold standard.