Case Presentation: 2 a.m. CT Findings

It’s 2 a.m. The on-call resident’s voice is shaky.
The CT shows an 18cm abdominal aortic aneurysm with a Type 1B endoleak.
There’s gas in the sac, fluid in the belly, and the patient has a defibrillator on both sides of his chest.
Is it a rupture? A graft infection? An aortoenteric fistula? All of the above?
You’re the vascular surgeon, what do you do? 

This episode dives deep into decision-making when EVAR fails, when infection strikes, and when the patient might not survive a definitive repair. Let’s talk about what happens when clinical textbooks meet real-world chaos.

Hosts:
·      Christian Hadeed -PGY 4 General Surgery, Brookdale Hospital Medical Center
·      Paul Haser -Division chief, Vascular Surgery, Brookdale Hospital Medical Center
·      Andrew Harrington, Vascular surgery, Brookdale Hospital Medical Center
·      Lucio Flores, Vascular surgery, Brookdale Hospital Medical Center

Learning objectives:
· Understand the clinical implications and management of late EVAR complications, including Type 1B endoleak and aortoenteric fistula.
· Explore the decision-making process in critically ill patients with multiple comorbidities and infected aortic grafts.
· Compare endovascular vs open surgical approaches in the setting of infected AAA, and when each is appropriate.
· Recognize the role of multidisciplinary collaboration in complex vascular cases.
· Discuss the ethical considerations and goals-of-care planning in high-risk, potentially terminal vascular patients.
· Highlight the importance of long-term surveillance after EVAR and the consequences of noncompliance.

References

·       Karl Sörelius et al.Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular Repair.Circulation. 2016;134(22):1822–1832.
PubMed: https://pubmed.ncbi.nlm.nih.gov/27799273/ pubmed.ncbi.nlm.nih.gov+15pubmed.ncbi.nlm.nih.gov+15researchgate.net+15

·       PARTNERS Trial (OVER Trial).Outcomes Following Endovascular vs Open Repair of Abdominal Aortic Aneurysm: A Randomized Trial.JAMA. 2009;302(14):1535–1542.
PubMed: https://pubmed.ncbi.nlm.nih.gov/19826022/ pubmed.ncbi.nlm.nih.gov+6pubmed.ncbi.nlm.nih.gov+6jamanetwork.com+6

·       B.T. Müller et al.Mycotic Aneurysms of the Thoracic and Abdominal Aorta and Iliac Arteries: Experience with Anatomic and Extra-anatomic Repair in 33 Cases.J Vasc Surg. 2001;33(1):106–113.
PubMed: https://pubmed.ncbi.nlm.nih.gov/11137930/ sciencedirect.com+5pubmed.ncbi.nlm.nih.gov+5periodicos.capes.gov.br+5

·       Chung‑Dann Kan et al.Outcome after Endovascular Stent Graft Treatment for Mycotic Aortic Aneurysm: A Systematic Review.J Vasc Surg. 2007 Nov;46(5):906–912.
PubMed: https://pubmed.ncbi.nlm.nih.gov/17905558/ researchgate.net+15pubmed.ncbi.nlm.nih.gov+15pubmed.ncbi.nlm.nih.gov+15

·       Hamid Gavali et al.Outcome of Radical Surgical Treatment of Abdominal Aortic Graft and Endograft Infections Comparing Extra‑anatomic Bypass with In Situ Reconstruction: A Nationwide Multicentre Study.Eur J Vasc Endovasc Surg. 2021;62(6):918–926.
PubMed: https://pubmed.ncbi.nlm.nih.gov/34782231/ pubmed.ncbi.nlm.nih.gov+6pubmed.ncbi.nlm.nih.gov+6diva-portal.org+6

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