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Title
A Hybrid Technique to Manage a Large Perigraft Seroma after an Open Abdominal Aortic Aneurysm Repair: A Case Report
Author(s) Alternative
Ono, S; Obara, H; Hagiwara, K; Saida, F; Oshiro, K; Matsubara, K; Shibutani, S; Kitagawa, Y
Journal Annals of vascular surgery, 56(): -URL http://hdl.handle.net/10130/5105 Right
A hybrid technique to manage a large perigraft seroma after an open abdominal
aortic aneurysm repair: A case report
Shigeshi Ono,1,2 Hideaki Obara,3 Kazuki Hagiwara,1 Fumitaka Saida,1 Kentaro Oshiro,1
Kentaro Matsubara,3 Shintaro Shibutani,1 and Yuko Kitagawa3
1Department of Vascular Surgery, Saiseikai Yokohamashi Tobu Hospital, Kanagawa,
Japan.
2Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba,
Japan.
3Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
Correspondence to: Hideaki Obara, MD, PhD, Department of Surgery, Keio University
School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, Japan; Telephone: 81-3-3353-1211; Fax: 81-3-3359-9130; E-mail: [email protected]
ABSTRACT
Perigraft seroma (PGS) is a relatively rare complication of aortoiliac reconstructive surgery. We herein describe a case of a large PGS that was managed by utilizing a hybrid technique of relining the original graft with simultaneous open drainage. An 86-year-old man with a 17.3-cm diameter PGS after prosthetic bifurcated graft replacement for abdominal aortic aneurysm was admitted to our hospital . He presented with abdominal distension and discomfort, and had difficulty in taking food. The entire relining of the original covered stent graft with GORE® EXCLUDER® using aortic extension cuff and iliac extenders and
simultaneous open evacuation of PGS were successfully p erformed. The symptoms of the patient totally improved, and no recurrence was
detected at 2 years after the operation. This technique would be a feasible treatment option for this rare complication.
Perigraft seroma (PGS) is a rare complication that occurs after implantation of vascular prosthetic grafts. Such seromas have been
reported after almost all types of vascular reconstructions, and especially after extra-anatomical bypass (1-3). The etiology of PGS still remains unclear.
It is reported that the radical treatment involves replacement of the whole prosthetic graft with a new graft made of an alternative material. The clinical and radiological manifestations of PGS are still unspecified, despite improved knowledge regarding the pathology.
The findings from our case highlight the efficacy of relining the entire graft using a stent graft with simple drainage of a huge seroma. The patient in this case consented to the publication of this report.
CASE REPORT
An 86-year-old man was admitted to our hospital with complaints of abdominal distension and discomfort due to a PGS. The patient had a history of chronic heart failure, coronary arterial bypass grafting,
for a long time.
Six-and-a-half years prior to admission, he had undergone an elective bifurcated graft replacement (GORE-TEX® Stretch Vascular graft, 16 × 8 mm; W.L. Gore, AZ, USA) for an abdominal aortic
aneurysm at another hospital. He underwent retroperitonization, and the postoperative course was uneventful. His PGS had been followed-up for several years at the hospital, and it gradually expanded.
At the time of admission, his blood pressure was 120/68 mmHg, pulse rate was 65 beats/min, and temperature was 36.2 °C. His abdomen was significantly distended, and a pulseless hard mass was palpable. The laboratory findings were as follows: white blood cell count 6,760/mm3,
hemoglobin 12.3 g/dL, eGFR 23, PT-INR 1.76, and C-reactive protein 1.36 mg/dL. A computed tomography (CT) scan revealed a 17.3 × 14.4-cm low-density mass around the prosthetic bifurcated graft , which compressed the abdominal wall and adjacent bowels (Fig. 1).
Definitive curative management was desired; however, due to his poor surgical risk, the hybrid technique of endovascul ar treatment and simple open evacuation was selected. Under general anesthesia, bilateral
common femoral arteries were exposed. The length from the lower renal artery to the graft bifurcation was not long enough to insert a
commercially available bifurcated stent graft; therefore, aortic extension cuff PXA230300J (W.L. Gore, AZ, USA) was predeployed to cover the proximal anastomosis (Fig. 2A), and iliac extenders PXC121400J (W.L. Gore, AZ, USA) were placed in each limb from inside the aortic cuff to the native common iliac artery (Fig. 2B) in almost the same way as the so-called kilt technique (4).
Following the placement of stent graft, an open laparotomy was performed through a midline incision. On exploration, the
retroperitoneum was significantly distended similar to an elastic hard mass, and the mesentery of the small intestine was adhered to the mass (Fig. 3). The retroperitoneum was opened and a serous blackish brown fluid (>2,000 ml) was aspirated. A jelly-like gelatinous mass was left around the graft, and this was removed as much as possible. Irrigat ion was performed with normal saline, and an elongated sac was resected carefully to avoid mesenteric injury, and retroperitonization was performed by tightly closing the sac. No drainage tube was placed.
On the 7th day of the operation, bare-metal stent (Express 10/37 mm and 10/58 mm; Boston Scientific, MA, USA) insertion to each graft limb was needed for limb ischemia. Apart from that, his postoperative course was uneventful. His symptoms improved completely, and a CT scan performed two years after the surgery revealed no evidence of recurrent PGS (Fig. 4).
DISCUSSION
A PGS, which is a rare complication of abdominal aortoiliac reconstructive surgery, is defined as “a collection of clear, sterile fluid confined within a nonsecretory fibrous pseudomembrane surrounding a vascular graft” by Blumenberg et al. (2). The reported incidence of PGS varies, ranging from 0.48% to 4.2%, because the estimation is difficult and might be underestimated (1, 5-7). Several etiologies, such as serous ultrafiltrate extravasation (1, 2, 8-10), activation of the fibrinolytic cascade(9), and immunological reaction to the prosthetic substance (1), have been considered; however, the exact cause still remains unclear. The larger pore size of ePTFE compared to Dacron has been considered
to cause a higher incidence of PGS (3), although, even now, there is no consensus about the advantages regarding the use of Dacron vs. ePTFE in avoiding PGS (7). Even a vein graft could cause PGS with 1% to 2% incidence (2), which makes the pathogenesis of PGS more difficult to understand. Bifurcated graft, anticoagulation therapy, smoking, and diabetes mellitus have been reported as the other risk factors for PGS (3).
Careful follow-up would be enough for most asymptomatic patients; however, surgical interventions should be considered for symptomatic ones, similar to our case. The most common symptoms of PGS are vague abdominal discomfort associated with sac expansion (2, 3), and chronic constipation or presence of abdominal mass (3, 9). Several treatment options have been reported, including simple
aspiration or open evacuation (11, 12) and injection of sclerosing agents (2); however, they are usually unsuccessful or have a high recurrence rate (3). The most promising option would be an entire graft replacement with an alternative material and evacuation (13), which is highly
(14); however, it would be difficult to recognize the causative lesion of PGS itself.
Relining the entire graft could be an alternative treatment to the graft replacement. In our case, the same material, ePTFE, was used to reline the original graft. Since mid-2004, low-permeability GORE® EXCLUDER® had been commercially available, which was redesign ed to reduce its porosity, and it was significantly associated with a greater aneurysm shrinkage rate compared to the original one (15). Our method could definitely reduce the effect of porosity and it was feasible
regardless of the material.
In the growing endovascular aneurysm repair (EVAR) era, endotension without any endoleak, which is called Type V, has been experienced. Endotension-related rupture was also reported, and Filippi et al. treated the condition by relining with another stent graft (16). Zimpfer et al. also reported the efficacy of a redo stent graft for sac enlargement by the endotension (17). The incidence of Type V endoleak has been reported to be about 1.5% to 5% (18, 19), which is almost the same as PGSs. This could imply that the etiology of endotension was
related to PGSs. The relining technique with open evacuation would be a feasible method.
CONCLUSION
We successfully performed the hybrid technique of relining the original graft with open drainage to manage a large PGS. This could also be a treatment option for endotension with sac enlargement in this EVAR era.
Declarations of interest None.
FIGURE CAPTIONS
Fig. 1 Computed tomography scan reveals a 17.3 × 14.4-cm low-density mass around the prosthetic graft.
Fig. 2 A. The arrow shows the proximal suture line of the graft during an open surgery. B. The original graft is completely relined with a stent graft. The arrows show the proximal suture line of the graft and arrowheads showing the distal ones during an open surgery.
Fig. 3 Intraoperative finding. Significantly distended retroperitoneum.
Fig. 4 The computed tomography scan two years after the surgery reveals no recurrence of perigraft seroma
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