Robinson Nathaniel, Tallarita Tiziano, Beckermann Jason, Nijhawan Vinay, McBride Jeremy, Saran Nishant, Carmody Thomas, Wildenberg Joseph
Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.
Department of Vascular Medicine and Surgery, Mayo Clinic Health System, Eau Claire, WI, USA.
AME Case Rep. 2024 May 30;8:70. doi: 10.21037/acr-23-148. eCollection 2024.
Type II endoleaks are common and embolization is often performed if treatment is necessary. Although transarterial embolization is common, other methods including trans-caval embolization are also utilized. Complications can occur and we report a case of infection that was challenging to diagnose and treat. There is no data regarding the risk of aortic stent graft infection after trans-caval embolization with n-butyl 2-cyanoacrylate (n-BCA) glue of a type II endoleak.
We report a rare case of infected, Gore Excluder infrarenal stent graft after transcaval embolization with coil and n-BCA glue to treat a type II endoleak in a 71-year-old male. The endoleak caused a rapid sac enlargement. The stent graft was placed 5 years earlier electively. Soon after the endoleak embolization, the patient experienced abdominal pain and malaise. There was an intense inflammatory reaction involving the aneurysm wall and the adjacent bowel mesentery. Our differential included normal inflammation after embolization vs. infection and this was difficult to distinguish. The infection was confirmed by positron emission tomography scan and tissue biopsy. The patient was deemed high-risk for surgery because of his extensive cardiac history, status post coronary bypass and tissue mitral valve replacement, congestive heart failure with residual left ventricular ejection fraction of 36%. He was optimized by correcting fluid status, administration of intravenous antibiotic, and nutrition consultation with dietary supplementation before surgery over the course of 2 weeks. The graft was explanted through a transabdominal approach, and the aorta was reconstructed with cryopreserved allograft. Interestingly, the small and large intestine with their mesentery were found to be plastered to the aneurysm sac. The post-operative course was unremarkable except for a transient acute kidney injury that resolved within 1 week. Follow-up computed tomography scan at 6 months showed widely patent bypass.
Glue embolization induces inflammation promoting thrombus formation inside the aneurysm sac. With a transcaval approach to the sac, there is the risk of extravasation of glue outside the sac as well as contamination of the graft with instrumentation. Differentiating between inflammation and infection can be difficult, and tissue biopsy provided the most conclusive diagnosis. Risk minimization considerations include, pre-operative optimization, a transabdominal approach, ureteral stenting, and tissue buttressing of anastomosis.
II型内漏很常见，如有必要进行治疗，通常会进行栓塞。虽然经动脉栓塞很常见，但也会采用包括经腔静脉栓塞在内的其他方法。可能会出现并发症，我们报告一例诊断和治疗都颇具挑战性的感染病例。关于用正丁基2-氰基丙烯酸酯（n-BCA）胶对II型内漏进行经腔静脉栓塞后主动脉覆膜支架感染风险，尚无相关数据。
我们报告一例罕见病例，一名71岁男性因II型内漏接受线圈和n-BCA胶经腔静脉栓塞治疗后，Gore Excluder肾下覆膜支架发生感染。内漏导致瘤腔迅速扩大。覆膜支架是5年前择期置入的。内漏栓塞后不久，患者出现腹痛和不适。动脉瘤壁和相邻肠系膜出现强烈炎症反应。我们的鉴别诊断包括栓塞后的正常炎症与感染，这很难区分。通过正电子发射断层扫描和组织活检确诊为感染。由于患者有广泛的心脏病史、冠状动脉搭桥和二尖瓣置换术后状态、充血性心力衰竭且左心室射血分数残留36%，被认为手术风险高。在术前2周的时间里，通过纠正液体状态、静脉给予抗生素以及营养咨询和饮食补充对患者进行优化。通过经腹途径取出移植物，并用冷冻保存的同种异体移植物重建主动脉。有趣的是，发现小肠和大肠及其系膜粘连在动脉瘤囊上。术后过程除了1周内解决的短暂急性肾损伤外，无异常。6个月后的随访计算机断层扫描显示旁路广泛通畅。
胶水栓塞会引发炎症，促进动脉瘤腔内血栓形成。采用经腔静脉途径进入瘤腔，存在胶水溢出瘤腔以及器械污染移植物的风险。区分炎症和感染可能很困难，组织活检提供了最具决定性的诊断。风险最小化考虑因素包括术前优化、经腹途径、输尿管支架置入以及吻合口的组织支撑。
