Acute aortic occlusion secondary to aortic endograft migration and collapse

Endograft migration after endovascular aneurysm repair (EVAR) is known to predispose to type Ia endoleaks and aneurysm growth but rarely leads to ischemic complications. We describe the case of a patient who presented with acute limb ischemia secondary to endograft collapse and subsequent aortic occlusion. Informed consent was obtained from the patient. The patient, a 75-year-old man, underwent EVAR with an AneuRx device (Medtronic, St. Paul, Minn) at an outside institution. Postoperative computed tomography demonstrated good endograft position and aneurysm exclusion (A). He was subsequently lost to follow-up. Four years later, he presented to the outside institution with bilateral lower extremity weakness. Additional past medical history included coronary artery disease and chronic obstructive pulmonary disease due to a 75 pack-year smoking history. Computed tomography angiography was performed and showed significant migration of the proximal endograft into the aneurysm sac, with subsequent kinking and complete occlusion of the graft (B-D). At the time of transfer to our institution, the lower extremities were pulseless and insensate below the knee, with complete paralysis of the right leg and significant paresis of the left leg. He was taken to the operating room emergently and underwent an axillobifemoral bypass with bilateral femoral artery thrombectomies and lower leg fasciotomies. On completion, he had return of pedal pulses bilaterally. After a prolonged hospitalization, he was discharged to a skilled nursing facility in good condition. At 1-year follow-up, he was ambulating with minimal assistance and had a widely patent bypass graft by duplex ultrasound imaging. Aortic endograft collapse is rare and is primarily described in the thoracic aorta. Four cases of abdominal aortic endograft collapse after EVAR have been reported to date, two resulting in type Ia endoleak and one resulting in graft occlusion and lower extremity ischemia. Factors predisposing to graft collapse after EVAR are unknown but likely include both anatomic and endograft-specific factors. In this patient, neck degeneration and lack of active proximal endograft fixation likely contributed to migration of the endograft into the aneurysm sac and subsequent collapse. This case emphasizes the need for ongoing surveillance after EVAR to prevent such complications.