Rare complication of esophageal necrosis and perforation after fenestrated endovascular aneurysm repair

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Abstract

Fenestrated endovascular aneurysm repair (FEVAR) is a minimally invasive technique used to treat complex abdominal aortic aneurysms. We present the case of a 69-year-old man with a juxtarenal abdominal aortic aneurysm treated with FEVAR. The patient experienced postoperative dysphagia and sepsis. Investigations revealed a perforated esophagus due to esophageal ischemia and necrosis, leading to complete esophagectomy and subsequent esophageal reconstruction. This case highlights esophageal necrosis and perforation as a potential complication of FEVAR and serves as a reminder to have a low threshold for investigating and emergently managing this condition, which otherwise has a high mortality rate.

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Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management.

Dania Daye, T Walker (2018)

In recent decades, endovascular aneurysm repair or endovascular aortic repair (EVAR) has become an acceptable alternative to open surgery for the treatment of thoracic and abdominal aortic aneurysms and other aortic pathologies such as the acute aortic syndromes (e.g., penetrating aortic ulcer, intramural hematoma, dissection). Available data suggest that endovascular repair is associated with lower perioperative 30-day all-cause mortality as well as a significant reduction in perioperative morbidity when compared to open surgery. Additionally, EVAR leads to decreased blood loss, eliminates the need for cross-clamping the aorta and has shorter recovery periods than traditional surgery. It is currently the preferred mode of treatment of thoracic and abdominal aortic aneurysms in a subset of patients who meet certain anatomic criteria conducive to endovascular repair. The main disadvantage of EVAR procedures is the high rate of post-procedural complications that often require secondary re-intervention. As a result, most authorities recommend lifelong imaging surveillance following repair. Available surveillance modalities include conventional radiography, computed tomography, magnetic resonance angiography, ultrasonography, nuclear imaging and conventional angiography, with computed tomography currently considered to be the gold standard for surveillance by most experts. Following endovascular abdominal aortic aneurysm (AAA) repair, the rate of complications is estimated to range between 16% and 30%. The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38%. Common complications include both those related to the endograft device and systemic complications. Device-related complications include endoleaks, endograft migration or collapse, kinking and/or stenosis of an endograft limb and graft infection. Post-procedural systemic complications include end-organ ischemia, cerebrovascular and cardiovascular events and post-implantation syndrome. Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively. Typically, most secondary reinterventions involve the use of percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, enhancement of endograft fixation, treatment of certain endoleaks using various embolization techniques and embolic agents and thrombolysis of occluded endograft components. Less commonly, surgical conversion and/or open surgical modification are required. In this article, we provide an overview of the most common complications that may occur following endovascular repair of thoracic and AAAs. We also summarize the current surveillance recommendations for detecting and evaluating these complications and discuss various current secondary re-intervention approaches that may typically be employed for treatment.

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Diagnosis and management of acute esophageal necrosis

Emanuel Dias, João Santos-Antunes, Guilherme Macedo (2019)

Acute esophageal necrosis is a rare syndrome classically characterized by a striking endoscopic image of diffuse and circumferential black mucosal discoloration of distal esophagus, with an abrupt transition at the gastroesophageal junction and variable proximal extension. The typical patient is an older male with general debilitation and multiple comorbidities presenting with hematemesis or melena. The pathophysiology usually involves a combination of esophageal ischemia, backflow injury from gastric chemical contents and impaired mucosal reparative mechanisms associated with debilitated physical states. It may arise in the setting of hemodynamic compromise, diabetic ketoacidosis, hypothermia, alcoholic intoxication, trauma, inflammatory diseases, esophageal local infection, solid organ transplantation, postoperative status, drugs or acute gastric outlet obstruction, usually in the background of a chronic debilitating process, where the concurrent presence of multiple risk factors, including diabetes mellitus, hypertension, malnutrition, malignancy or alcohol abuse, places a patient at higher risk. The characteristic endoscopic appearance establishes the diagnosis. Biopsy is supportive but not required. Management is mainly supportive and consists of correcting coexisting conditions, fluid therapy, bowel rest, intravenous proton pump inhibitor therapy and red blood cell transfusion as needed. Although this is a serious life-threatening condition, appropriate treatment may result in a favorable outcome in the majority of patients.

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Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome.

Elaine Hallisey, Paul V Vignati, Ira Kim … (2008)

To examine the safety, efficacy, and predictors of outcome of angiographic embolization in the management of gastroduodenal hemorrhage. Retrospective record review. University-affiliated tertiary care center. All of the patients were referred after endoscopic treatment failure. Surgery was not immediately considered because of poor surgical risk, refusal to consent, or endoscopist's decision. Patients with coagulopathy, hemobilia, and variceal or traumatic upper gastrointestinal tract bleeding were excluded from review. Between January 1, 1996, and December 31, 2006, 70 embolization procedures were performed in 57 patients. Technical success rate (target vessel devascularization), clinical success rate (in-hospital cessation of bleeding without further endoscopic, radiologic, or surgical intervention), and complications. The technical success rate was 94% (66 of 70 angiographies). The primary clinical success rate was 51% (29 of 57 patients), and the clinical success rate after repeat embolization was 56% (32 of 57 patients). Two factors were found to be independent predictors of poor outcome by multivariate analysis: recent duodenal ulcer suture ligation (P = .03) and blood transfusion of more than 6 units prior to the procedure (P = .04). There was no predictive value for angiographic failure based on age, sex, prior coagulopathy, renal failure at presentation, immunocompromised status, multiple organ system failure, empirical (blind) embolization, and use of permanent vs temporary embolic agents. Repeat embolizations were helpful for postsphincterotomy bleeding. Major ischemic complications (4 patients [7%]) were associated with previous foregut surgery. Angiographic embolization for gastroduodenal hemorrhage was associated with in-hospital rebleeding in almost half of the patients. Angiographic failure can be predicted if embolization is performed late, following blood transfusion of more than 6 units, or for rehemorrhage from a previously suture-ligated duodenal ulcer.

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Neeral R. Patel

Journal

Journal ID (nlm-ta): J Vasc Surg Cases Innov Tech

Journal ID (iso-abbrev): J Vasc Surg Cases Innov Tech

Title: Journal of Vascular Surgery Cases and Innovative Techniques

Publisher: Elsevier

ISSN (Electronic): 2468-4287

Publication date PMC-release: 13 April 2020

Publication date Collection: June 2020

Publication date (Electronic): 13 April 2020

Volume: 6

Issue: 2

Pages: 181-184

Affiliations

[a ]Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada

[b ]Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada

Author notes

[∗ ]Correspondence: Neeral R. Patel, MBBS, BSc, FRCR, Interventional Radiology, Toronto General Hospital, University Health Network, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4 neeral.patel@ 123456uhn.ca

Article

Publisher ID: S2468-4287(20)30022-8

DOI: 10.1016/j.jvscit.2020.02.004

PMC ID: 7160524

SO-VID: 5c9d648f-4dbd-4076-b223-ff67ce2799f7

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This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Rare complication of esophageal necrosis and perforation after fenestrated endovascular aneurysm repair

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Most cited references 13

Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management.

Diagnosis and management of acute esophageal necrosis

Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome.

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