Aortic endograft complications
Background
Patients with Endovascular Aortic Repair (EVAR) can have unique complications that are not discussed in most emergency medicine literature. EVAR has largely replaced open aortic repair as the gold standard for the treatment of Abdominal Aortic Aneurysm (AAA). Common complications including aortoenteric fistula, endoleaks, and graft thrombosis can present in a similar fashion to other common ED diagnoses. Understanding these complications can guide treatment and disposition of these patients.
Clinical Features
The presentation can vary based on the underlying issue with the graft. Most symptoms are non-specific and include nausea, vomiting, abdominal pain, hematochezia, and back pain.
Differential Diagnosis
- complications unique to EVAR
- Aortoenteric Fistula (most common)
- Endoleaks
- Limb ischemia
- Graft thrombosis
- Graft infection
- Renal artery Occlusion
- Colonic ischemia
- Spinal cord ischemia
Evaluation
- Physical
- There are no exam findings which reliably rule in or out these diagnoses.
- Labs
- CBC, CMP, Lipase, Type and Screen, UA, +/- Blood cultures(graft infection), +/- Lactate(suspected mesenteric ischemia)
- Imaging
- CT- for the highest sensitivity a triple phase CT scan (non-contrast, arterial phase, delayed phase) is required. Usually you want to talk with radiology prior to this study.
- Ultrasound- both point of care ultrasound and duplex ultrasound do not detect EVAR complications with high enough sensitivity to be use routinely.
Management
- Coordination of care with vascular surgery is recommended when a graft issue is suspected- consult early
- balanced resuscitation and early antibiotics if infection is suspected.
Disposition
- Knowing the unique complications of EVAR is the first and most important step in the management of these patients.
- Unfortunately, while CT is sensitive for most complications of EVAR it does NOT definitively exclude Aortoenteric Fistula, Graft infection or endoleaks. Maintain a high index of suspicion and when a EVAR issue is suspected always lean toward conservative management and early specialist consultation.