Aneurysm expansion and retroperitoneal hematoma after thrombolysis for stent-graft limb occlusion caused by distal endograft migration.
OBJECTIVE
To describe a complication of thrombolytic therapy used to treat graft limb occlusion precipitated by distal migration and kinking of an abdominal aortic stent-graft.


METHODS
A 5.5-cm abdominal aortic aneurysm (AAA) in a 66-year-old woman was treated with Vanguard bifurcated stent-graft. At the 1-year follow-up, she complained of left leg claudication. Computed tomography (CT) showed a 36% reduction in maximum AAA diameter, but the stent-graft had migrated distally approximately 5 mm, and the left graft limb was occluded. Thrombolysis was initiated, but after approximately 8 hours, abdominal pain began. Emergent CT scanning revealed rapid aneurysm expansion and a retroperitoneal hematoma. Thrombolytic treatment was stopped; transfusions and thrombogenic drugs were given to restore hemodynamic stability. The aneurysm began to decrease in size. The occluded graft limb had been reopened by the lytic therapy, uncovering a stenosis in the native artery distal to the graft limb. Stent placement restored outflow. The retroperitoneal hematoma resolved over time, and the aneurysm sac shrank to its prelytic diameter. The patient is well with a functioning endograft 18 months after the occlusion (30 months after stent-grafting).


CONCLUSIONS
Caution must be taken when using thrombolysis in patients with endovascular aortic grafts because unexpected bleeding complications might arise. Thrombectomy, femorofemoral bypass, or stent or stent-graft extensions might be safer alternatives for treating occluded stent-graft limbs.
Resch
T
T
Department of Surgery, Malmö University Hospital, Lund University, Sweden. Tim.Resch@rontgen.mas.lu.se
Lindblad
B
B
Lindh
M
M
Brunkwall
J
J
Ivancev
K
K
D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000139:chemically induced / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography; D001807:Blood Vessel Prosthesis; D005260:Female; D005548:Foreign-Body Migration / Q000150:complications* / Q000000981:diagnostic imaging; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000601:surgery*; D006406:Hematoma / Q000139:chemically induced* / Q000000981:diagnostic imaging; D006801:Humans; D011475:Prosthesis Failure; D012008:Recurrence; D012086:Reoperation; D015607:Stents; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed
D010959:Tissue Plasminogen Activator