Gambaro Esteban, Abou-Zamzam Ahmed M, Teruya Theodore H, Bianchi Christian, Hopewell James, Ballard Jeffrey L
Department of Surgery, Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
Ann Vasc Surg. 2004 Jan;18(1):74-8. doi: 10.1007/s10016-003-0102-2. Epub 2004 Jan 12.
Endoleaks remain a significant challenge after endovascular abdominal aortic aneurysm repair (EVAR). Translumbar thrombin injection of the aneurysm sac has been used to treat endoleaks, with low reported morbidity. We present an unusual case of ischemic colitis following translumbar thrombin injection of an endoleak. A 67-year-old male with a 5.8-cm abdominal aortic aneurysm (AAA) was evaluated for endograft repair. The patient underwent preoperative embolization of the right hypogastric artery. The AAA was repaired using a unibody bifurcated graft (Ancure). Completion aortogram revealed no endoleak and a widely patent left hypogastric artery. Computed tomography (CT) at 2 months showed an endoleak appearing to originate from a lumbar artery near the proximal attachment site with outflow via the inferior mesenteric artery (IMA). The endoleak was successfully treated with CT-guided translumbar injection of 8000 units of thrombin into the aneurysm sac. The patient subsequently developed chronic abdominal pain, diarrhea, and a weight loss of 20 lbs. Colonoscopy revealed ischemic colitis of the rectosigmoid colon. Duplex evaluation indicated a patent superior mesenteric artery and IMA distal to its origin. Medical treatment failed and the patient underwent a low anterior resection 2 months later (4 months post-EVAR). Subsequently, the aneurysm has decreased to 5.4 cm, with no evidence of endoleak at 1 year. We conclude that ischemic colitis may occur following translumbar thrombin injection. Thrombin embolization into the rectosigmoid arcade via the IMA was most likely the cause in this case. This problem can potentially be avoided by treating the IMA endoleak outflow prior to translumbar thrombin injection of the aneurysm sac. Thorough arteriographic evaluation of endoleaks should be performed prior to any interventions.
在血管腔内腹主动脉瘤修复术（EVAR）后，内漏仍然是一个重大挑战。经腰动脉向动脉瘤腔内注射凝血酶已被用于治疗内漏，据报道其发病率较低。我们报告了一例经腰动脉注射凝血酶治疗内漏后发生缺血性结肠炎的罕见病例。一名67岁男性，患有5.8厘米的腹主动脉瘤（AAA），接受了腔内修复评估。患者术前接受了右下腹动脉栓塞术。使用一体式分叉移植物（Ancure）修复了AAA。主动脉造影显示无内漏，左下腹动脉广泛通畅。术后2个月的计算机断层扫描（CT）显示内漏似乎起源于近端附着部位附近的腰动脉，并通过肠系膜下动脉（IMA）流出。通过CT引导经腰动脉向动脉瘤腔内注射8000单位凝血酶成功治疗了内漏。患者随后出现慢性腹痛、腹泻，体重减轻20磅。结肠镜检查显示直肠乙状结肠缺血性结肠炎。双功超声评估显示肠系膜上动脉通畅，IMA在其起源远端。药物治疗无效，患者在2个月后（EVAR术后4个月）接受了低位前切除术。随后，动脉瘤缩小至5.4厘米，1年后无内漏迹象。我们得出结论，经腰动脉注射凝血酶后可能发生缺血性结肠炎。在本例中，凝血酶经IMA栓塞至直肠乙状结肠动脉弓很可能是病因。在经腰动脉向动脉瘤腔内注射凝血酶之前，通过治疗IMA内漏流出道，有可能避免这个问题。在进行任何干预之前，应进行全面的动脉造影评估内漏情况。
