Interact CardioVasc Thorac Surg 2006;5:121-122. doi:10.1510/icvts.2005.124149
© 2006 European Association of Cardio-Thoracic Surgery
Erosion of lumbar vertebral bodies by an anastomotic false aneurysm late after implantation of a prosthetic aortic bifurcated graft
Carlos-A. Mestres*,
Salvador Ninot and
Jaime Mulet
Department of Cardiovascular Surgery, Hospital Clinico, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
Received 2 November 2005;
received in revised form 4 December 2005;
accepted 12 December 2005
*Corresponding author. Tel.: +34-93-2275515; fax: +34-93-4514898.
E-mail address: cmestres{at}clinic.ub.es (C.-A. Mestres).
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Abstract
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False aneurysms are seen at any anastomotic level. Erosion of surrounding structures is a rare event that needs surgical treatment. The case of a patient with proximal Dacron bifurcated graft false aneurysm eroding lumbar vertebral bodies is presented. This is an uncommon but very serious complication from aortic grafts.
Key Words: Aortic Dacron grafts; False aneurysm; Vertebral erosion
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1. Introduction
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Among the less frequent, false aneurysms eroding and invading surrounding structures can be found. Vertebral erosion is an uncommon complication on the long-term run. Here we present the case of a patient who developed a proximal false aneurysm of a bifurcated graft resulting in vertebral erosion.
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2. Case report
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A 58-year-old male with a history of hyperlipidemia, coronary artery disease and pulmonary tuberculosis underwent aortofemoral revascularization with a Dacron bifurcated graft in 1997 at another institution due to aortoiliac occlusion. He was referred to us with a 6-month chief complaint of left lumbar pain. Magnetic resonance disclosed an anastomotic aneurysm measuring 150x70x70 mm with erosion of L2 and L3 vertebral bodies (Figs. 1, 2). Preoperative white count and C-reactive protein were within normal limits. Digital subtraction angiography confirmed the proximal false aneurysm and anastomotic femoral aneurysms. Indication for reoperation was unbearable pain and obvious expansive false aneurysm with a high risk of rupture. Exposure of the bifurcated graft and false aneurysm eroding the vertebral bodies was achieved through midline laparotomy and bilateral inguinal access. The duodenum was stuck to the graft. The false aneurysm and bifurcation graft were resected with supraceliac clamping. Vascular continuity was achieved with a composite cryopreserved vascular homograft including a segment of thoracic aorta, aortic bifurcation and two iliac arteries. No attempt to manage vertebral erosion was made as the patient had no neurological symptoms. The patient required intraoperative inotropic support and after surgery presented with coagulopathy, bilateral compartmental syndrome and organ failure possibly related to supraceliac clamping. He eventually died 24 h later. No postmortem examination was allowed. Laboratory analysis failed to demonstrate bacterial growth in the explanted vascular prosthesis and false aneurysmal thrombus.
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Fig. 1. Magnetic resonance imaging. Lateral view. Erosion of L2–L3 bodies. In this view the large clot that occupies the false aneurysm can be seen and the anastomotic line should be located at the level of L4–l5 interspace.
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Fig. 2. Magnetic resonance imaging. Transverse view of the large false aneurysm eroding the vertebral body. The anterior and left aspect of the vertebral body is clearly in contact with the false aneurysm that contains a large quantity of clot.
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3. Discussion
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Aortic pathology rarely leads to vertebral body lesions. Single abdominal aortic aneurysm or in association with inflammatory disorders has been identified as a cause of vertebral erosion [1]. Anastomotic aortic aneurysms are even rarer as leading to bone loss with just a handful of cases reported [2]. In the case presented herein, ureteral lesions were ruled out and symptoms were initially attributed to spinal disease. Large bony loss was later confirmed. Surgery must be performed on an urgent basis. We chose a composite cryopreserved homograft from our tissue bank as the possibility of infection had to be considered. However, bacteriology did not show pathogen growth as it has been observed. Endovascular treatment may not be appropriate in the setting of possible vascular infection. It is difficult to establish the possible role of endovascular therapy in similar cases. The fatal outcome of this case confirms the seriousness of this pathology. Even though we were unable to confirm active inflammation, this is a chronic process and inflammation/infection has always to be suspected.
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References
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- Wang K, Hodges M. Erosion of lumbar vertebral bodies due to abdominal aortic aneurysm. Circulation 1994; 89:1317.[Free Full Text]
- Diekerhof CH, Reedt Dortland RWH, Oner FC, Verbout AJ. Severe erosion of lumbar vertebral body because of abdominal aortic aneurysm. Spine 2002; 27:E382–E384.[Medline]
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Abstract
1. Introduction