Management of Aortic Sac Enlargement Following Successful EVAR in a Frail Patient.
BACKGROUND
An enlarging aneurysm after endovascular aneurysm repair (EVAR) without clear endoleak is a clinical challenge. Management of this problem is guided by the current evidence for adequate EVAR follow up and recommended thresholds for re-intervention. In a frail patient, careful risk assessment of aneurysm related mortality against the risks associated with examinations and interventions is required.


METHODS
The literature was reviewed for imaging modalities for EVAR follow up and their advantages and disadvantages. The current evidence and guideline recommendations regarding follow up and re-intervention after EVAR were assessed in relation to the presented case.


RESULTS
To detect sac expansion after EVAR, repeated examinations with the same imaging modality are needed. Verified expansion must be above the inter-observer variation of the method used. Although duplex ultrasound is an excellent modality for EVAR follow up, the finding of a significant expansion on duplex requires further examination, primarily with computed tomography angiography to assess sealing, stent graft integrity, and presence of endoleak. A frail patient should be assessed thoroughly before any kind of surgical intervention, the extent of which is related to the identified or suspected cause of expansion.


CONCLUSIONS
Failure to totally exclude the aneurysm from continuing circulation, pressure and endoleak remains a potential shortcoming of EVAR. Significant sac expansion is an indication of EVAR failure. Decisions regarding further examinations or intervention are guided by the stability of the initial EVAR performed, the cause and extent of expansion, and the patient's comorbidities.
Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 75185 Uppsala, Sweden.
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Dellagrammaticas
Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 75185 Uppsala, Sweden.
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Baderkhan
Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 75185 Uppsala, Sweden. Electronic address: kevin.mani@surgsci.uu.se.
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Mani
D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation; D015897:Comorbidity; D018450:Disease Progression; D057510:Endovascular Procedures; D005260:Female; D016330:Frail Elderly; D006801:Humans; D018810:Magnetic Resonance Angiography; D064847:Multimodal Imaging / Q000379:methods; D015588:Observer Variation; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex
Abdominal aortic aneurysm; Follow up