Endovasküler anevrizma onarýmý (EVAR), uygulama kolaylýðý, hastanede kalýþ süresinin kýsalmasý ve açýk cerrahiyi tolere edemeyen hastalar için iyi bir alternatif olmasý nedeniyle abdominal aort anevrizmalarý (AAA) için giderek popülerlik kazanan bir tedavi yöntemidir. EVAR'ýn erken dönem sonuçlarý açýk cerrahiye göre daha iyi olmakla birlikte, endoleak, migrasyon, endogreft uzuvlarýnda tromboz/kývrýlma, greft enfeksiyonu ve sekonder rüptür gibi komplikasyonlar görülebilir. Bu çalýþmada, yaklaþýk 10 yýl önce baþka bir kurumda EVAR uygulanan ve genel durumunda bozulma, ateþ ve melena þikayetleriyle kliniðimize baþvuran bir hastayý sunuyoruz. 73 yaþýnda erkek hastanýn laboratuvar incelemesinde beyaz kan hücresi (WBC) sayýsý 17100, hemoglobin düzeyi 9,5 g/dL ve C-reaktif protein (CRP) düzeyi 261 g/L olarak bulundu. Bilgisayarlý tomografi (BT), EVAR greftinde tromboz, greft etrafýnda serbest hava, greft stentlerinde kýrýklar ve sað bacaðýn iliak bifurkasyon seviyesinde aortun dýþýna yer deðiþtirdiðini gösterdi. Endogreftin duodenuma doðru göç ettiði ve fistülleþtiði görüldü. Sepsis ile baþvuran hasta acil ameliyata alýndý. Ýlk olarak sol bacaktaki iskemiyi gidermek için sol aksillofemoral bypass yapýldý. Daha sonra genel cerrahi ve kalp damar cerrahisi bölümlerinin ortak katýlýmýyla laparotomi yapýldý. Karýn içi fekal kontaminasyon ve sigmoid kolon rüptürü görüldü. Karýn yýkandý, sigmoid kolon ve rektum eksize edildi ve kolostomi oluþturuldu. Daha sonra aortotomi yapýlarak greftin ana gövdesi ve sol bacaðý çýkarýldý. Duodenum açýldý ve fistülize olmuþ sað bacak endogrefti de çýkarýldý. Karýn içi kontaminasyon, sað bacakta muhtemelen kronik sürece baðlý yeterli kollateral dolaþým ve iskemi olmamasý nedeniyle ek vasküler giriþime gerek duyulmadý. Aort infrarenal seviyede baðlandý ve hasta yüksek inotropik destek alarak yoðun bakým ünitesine alýndý. Hasta, postoperatif 8. saatte kaybedildi. Bilgilerimize göre, literatürde daha önce bildirilmemiþ bu nadir ve benzersiz olguyu sunmamýzýn amacý, EVAR'ýn uzun dönem komplikasyonlarýna dikkat çekmek ve yüksek yaþam beklentisi olan hastalarda açýk cerrahinin önemini vurgulamaktýr.

Anahtar Kelimeler: Abdominal aort anevrizmasý, endovascular anevrizma onarýmý, uzun dönem komplikasyon

Rare and fatal late-term complication of endovascular aneurysm repair: migration of the endograft into the duodenum

Endovascular aneurysm repair (EVAR) is a treatment method that is increasingly popular for abdominal aortic aneurysms (AAA) due to its ease of application, reduction in hospital stay, and being a good alternative for patients who cannot tolerate open surgery. Although the early results of EVAR are better than those of open surgery, complications such as endoleak, migration, thrombosis/kinking in the endograft limbs, graft infection, and secondary rupture may occur. In this study, we present a patient who underwent EVAR at another institution approximately 10 years ago and presented to our clinic with complaints of deterioration in general condition, fever, and melena. Laboratory examination of 73-year-old man revealed a white blood cell (WBC) count of 17100, hemoglobin of 9,5 g/dL, and C-reactive protein (CRP) of 261 g/L. Computed tomography (CT) revealed thrombosis in the EVAR graft, free air around the graft, fractures in the graft stents, and displacement of the right leg beyond the aorta at the level of the iliac bifurcation. The endograft was observed to migrate toward the duodenum and fistulize. The patient, who presented with sepsis, underwent emergency surgery. Initially, a left axillo-femoral bypass was performed to relieve ischemia in the left leg. A laparotomy was then performed with the joint participation of the general surgery and cardiovascular surgery departments. Intraabdominal fecal contamination and the rupture of the sigmoid colon were observed. The abdomen was lavage, the sigmoid colon and rectum were excised, and a colostomy was created. An aortotomy was then performed, removing the main body of the graft and its left leg. The duodenum was opened, and the fistulized right leg of the endograft was also removed. No additional vascular intervention was required due to contamination of the abdomen, adequate collateral circulation in the right leg, probably due to the chronic process, and no ischemia. The aorta was ligated at the infrarenal level, and the patient, receiving high inotropic support, was transferred to the intensive care unit. The patient, died at the 8th postoperative hour. To out knowledge, our aim in presenting this rare and unique case, which has not been previously reported in the literature, is to draw attention to the long-term complications of EVAR and to emphasize the importance of open surgery in patients with a high life expectancy.

Keywords: Abdominal aortic aneurysm, endovascular aneurysm repair, long-term complication.