Endovascular Abdominal Aortic Aneurysm Repair to Prevent Rupture in a Patient Requiring Lithotripsy

Endovascular abdominal aortic aneurysm repair to prevent rupture in a patient requiring lithotripsy

Rick de Graaf, MSc, Frank J. Veith, MD, Nicholas J. Gargiulo III, MD, Evan C. Lipsitz, MD, Takao Ohki, MD, PhD, and Harrie A. J. M. Kurvers, MD, New York, NY

Extracorporeal shock wave lithotripsy (ESWL) for urolithiasis may result in rupture of a coexistent abdominal aortic aneurysm (AAA). We report a patient who required ESWL and who had an AAA. Open surgery was precluded by morbid obesity and persisting incisional hernias after mesh repair. Endovascular AAA repair (EVAR) with bifurcated grafts was precluded by an 11-mm distal aorta. EVAR with stacked tubular AneuRx components was performed, followed by ESWL. The AAA was excluded, and the integrity and position of the endografts were not altered by ESWL. (J Vasc Surg 2003;38:1426-29.)

Since its introduction in 1982, extracorporeal shock stent. The proximal part of the left ureter was dilated and thick- wave lithotripsy (ESWL) has become the therapy of choice ened. An attempt to remove the stone with ureteral basket cathe- for most patients with renal and upper ureteral calculi. ters had been unsuccessful. An arteriogram (Fig 2) showed an Although ESWL is a highly effective and well-tolerated 18-mm-long infrarenal neck that tapered from 18 mm at its widest procedure, several side effects and complications have been to 15 mm at its smallest diameter. There was a 3-cm long distal reported, such as kidney rupture, psoas abscess formation, aortic neck that was 11 mm at its smallest diameter. The common portal and iliac vein thrombosis, and adjacent organ hema- and external iliac arteries were normal. Fig 3, A shows the anatomic toma.1,2 Another more dangerous complication of ESWL characteristics of the infrarenal aorta. is rupture of a coexisting AAA.1,3 This has occurred even A pigtail angiographic catheter was placed via the right bra- with small AAAs.4 Accordingly, elective AAA repair has chial artery in the suprarenal aorta to permit precise angiographic been advised before ESWL. The present report describes localization of the renal arteries and aortic bifurcation as the the management of a patient who required ESWL in the endografts were being deployed. We did not use a catheter placed presence of a 4.9-cm AAA. Open surgery was precluded by via the contralateral (left) iliac system for this purpose because of morbid obesity and a hostile abdominal wall. In addition, concerns that removal of the catheter after graft deployment might the patient’s aortic anatomy was not suitable for EVAR by prove difﬁcult or might dislodge the grafts. With the brachial standard techniques. catheter in place, via the right common femoral artery, a 22 French CASE REPORT sheath was placed in the aorta. Through this an 85 ϫ 16-mm AneuRx (Medtronic, Minneapolis, Minn) tube graft was placed, A 73-year-old woman who was to undergo ESWL for symp- with its distal end just above the aortic bifurcation. The sheath was tomatic ureteral calculi was seen for an asymptomatic infrarenal retracted, the graft was deployed, and the sheath was readvanced AAA, which had enlarged from 3.5 cm 3 years before to 4.9 cm. through the graft into the infrarenal aorta. Through this a 37.5 ϫ The patient was morbidly obese (190 pounds, 5 ft 3 in) and 20-mm AneuRx aortic cuff was precisely deployed under angio- hypothyroid, and had had multiple laparotomies and a left colec- graphic control with its proximal end just below the main renal tomy for diverticulitis. These were complicated by incisional her- arteries and its distal half entrapped by the 16-mm distal tube graft nias, which persisted despite multiple surgical repairs, including (Fig 3, B and Fig 4). two with mesh prostheses. Lithotripsy was successfully performed 2 weeks later. One year On physical examination, she had a massively protuberant abdomen and large left-sided irreducible hernias with an associated later, the patient remained asymptomatic, and a follow-up CT scan ﬂuid collection around the mesh (Fig 1). Despite this, her AAA was and plain radiographs showed the endograft in position with easily palpable. A computed tomographic (CT) scan demonstrated exclusion of the AAA and without an endoleak. a J-stent in the left ureter, with a 6-mm pelvic stone external to the

DISCUSSION From the Division of Vascular Surgery, Monteﬁore Medical Center, and Albert Einstein College of Medicine. ESWL has become the treatment of choice for most Competition of interest: none. renal and upper ureteral calculi. The presence of an AAA is Supported by grants from the James Hilton Manning and Emma Austin Manning Foundation, The Anna S. Brown Trust, the New York Institute considered a contraindication, due to the possibility of for Vascular Studies, the Dutch Heart Foundation, and the Niels Stensen aneurysm rupture. Some early studies suggest that ESWL Foundation. can be executed safely despite the presence of an aneurysm Reprint requests: Frank J. Veith, MD, Monteﬁore Medical Center, 111 East of the abdominal aorta.2,5 In contrast, later studies have 21th Street, Bronx, NY 10467-2490 (e-mail: [email protected]). reported rupture of AAAs, even those with smaller diame- Copyright © 2003 by The Society for Vascular Surgery. 1,4,3 0741-5214/2003/$30.00 ϩ 0 ters. This indicates that AAA repair should precede doi:10.1016/S0741-5214(03)00949-2 ESWL, and this was deemed advisable in our patient. 1426 JOURNAL OF VASCULAR SURGERY Volume 38, Number 6 de Graaf et al 1427

Fig 1. Preoperative CT scan shows a ﬂuid collection around the mesh hernia repair.

Fig 2. Preoperative angiogram shows the irregular proximal and distal necks of the AAA. JOURNAL OF VASCULAR SURGERY 1428 de Graaf et al December 2003

Fig 3. Left, Schematic representation of the anatomic characteristics of the infrarenal aorta and the AAA. Right, Schematic representation of the endovascular repair.

attachment of the endograft is as of yet unclear. Exposure to high-frequency ultrasound scanning may lead to dis- placement of the graft. To our knowledge, no reports have appeared on this subject. Our patient had major contraindications to open repair (obesity and multiple previous laparotomies complicated by incisional hernias). Therefore, EVAR seemed to be the best approach. However, she was not a candidate for any bifurcated graft because of her small (11-mm) distal aorta. One alternative would be an aortouniiliac or aortounifemo- ral endograft with a femorofemoral bypass. We thought this would be complex and would require placement of a pros- thetic graft in obese groin wounds. We, therefore, devised a way to overcome the anatomic difﬁculties in our patient. By the precise placement of two interlocking different diameter endografts (1 iliac limb and 1 aortic cuff), we were able to exclude the entire aneurysm sac. Our technique was similar to one described by York and his colleagues6 using stacked aortic AneuRx cuff endografts. Although a smaller Fig 4. Completion angiogram shows the 2 AneuRx grafts in place, diameter distal endograft might have proven effective, we exclusion of the aneurysm, and no sign of endoleak. were concerned that it might not provide as effective a seal as the 16-mm diameter tubular graft. When open repair of an AAA is contraindicated because Our experience with this single case also suggests that of multiple comorbidities, EVAR may be a good alterna- lithotripsy can be performed safely in the presence of an tive. However, the effect of ESWL on the integrity and endograft. Obviously, larger series are needed to conﬁrm this. JOURNAL OF VASCULAR SURGERY Volume 38, Number 6 de Graaf et al 1429

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