The aim of this report is to discuss emergent repair for complex aortic diseases in patients affected by novel coronavirus pneumonia (coronavirus disease-2019 [COVID-19]), describing a case of ruptured pararenal aortic aneurysm. An eighty-year-old man with COVID-19 was admitted for ruptured aneurysm of the pararenal aorta and hemorrhagic shock. Endovascular repair was chosen, and a proximal extension of the previous abdominal endograft was performed with parallel stents in the right renal artery and the superior mesenteric artery. Endovascular treatment and early anticoagulation are the key for success for vascular emergencies in patients with COVID-19, despite the risk of late endoleak

Marazzi G.

Marone E. M.

Rinaldi L. F.

English

Archivio Istituzionale della Ricerca - Università degli Studi di Pavia

Conflict ofNo fundin1VascularPediatric Scien2Vascularpital PoliclinicCorrespondSurgical, DiagBrambilla 74,Ann Vasc Surhttps://doi.org/ 2020 ElseviManuscript re2020; publisheEndovascular Treatment of a RupturedPararenal Abdominal Aortic Aneurysm in aPatient With Coronavirus Disease-2019:Suggestions and Case ReportLuigi Federico Rinaldi,1 Giulia Marazzi,1 and Enrico Maria Marone,1,2 Pavia, ItalyThe aim of this report is to discuss emergent repair for complex aortic diseases in patientsaffected by novel coronavirus pneumonia (coronavirus disease-2019 [COVID-19]), describinga case of ruptured pararenal aortic aneurysm. An eighty-year-old man with COVID-19 wasadmitted for ruptured aneurysm of the pararenal aorta and hemorrhagic shock. Endovascularrepair was chosen, and a proximal extension of the previous abdominal endograft was per-formed with parallel stents in the right renal artery and the superior mesenteric artery. Endovas-cular treatment and early anticoagulation are the key for success for vascular emergencies inpatients with COVID-19, despite the risk of late endoleak.The novel coronavirus (NCoV) pandemic is affectingall aspects and fields of the medical profession,compelling physicians and surgeons to rethink theirway of work and therapeutic choices to comply withthe new challenges and the changes in their workenvironment.1 Although the NCoV pneumonia(coronavirus disease-2019 [COVID-19]) has spreadworldwide, affecting millions of people, to ourknowledge, no experience has been reported onthe management of major vascular emergencies inpatients with COVID-19 yet. The aim of the presentcase report on a ruptured pararenal abdominalaortic aneurysm (AAA) is to offer some consider-ation on this matter from the standpoint of a hubhospital for patients with COVID-19 in Lombardy,interest: None.g was received regarding the publication of this article.Surgery, Department of Clinical-Surgical, Diagnostic andces, University of Pavia, Pavia, Italy.Surgery, Department of Surgical Sciences, Teaching Hos-o S. Matteo, Pavia, Italy.ence to: Luigi Federico Rinaldi, Department of Clinical-nostic and Pediatric Sciences, University of Pavia, Viale27100 Pavia, Italy; E-mail: luigif.rinaldi@gmail.comg 2020; 66: 18–2310.1016/j.avsg.2020.05.011er Inc. All rights reserved.ceived: April 30, 2020; manuscript accepted: May 9,d online: 15 May 2020the Italian region that has been affected the mostby the pandemic.MATERIALS AND METHODSAnonymized publication of the patient’s data wasapproved by the competent institutional reviewboard.An 80-year-old man, undergone endovascularaortic repair (EVAR) in 2013 for an infrarenalAAA and lost to follow-up for 5 years, was referredto the unit of vascular surgery for severe abdominalpain, hypotension (blood pressure [BP]: 60/35 mmHg), and eventually loss of consciousness.Most significant comorbidities were previous rectalcancer, treated by Hartmann’s resection and left ter-minal colostomy confection, postincisional hernia ofthe abdominal midline, and chronic kidney failurewith left kidney shrinkage. Although no respiratorysymptoms such as dyspnea, cough, or fever were re-ported, the routine chest X-ray performed at theadmittance showed a consolidation patternspreading at the inferior lobes of the lungs (Fig. 1),and the nasal swab turned positive for NCoV (labo-ratory tests are reported in Table I). A computed to-mography angiography (CTA) was performed,showing a free rupture of the pararenal abdominalaorta, right above the previous endograft at the level18Fig. 1. Chest X-ray showing initial basal consolidationpattern (red arrow).19 Case reports Annals of Vascular Surgeryof the renal arteries, and a massive intraperitonealhematoma (Figs. 2 and 3). Open surgical treatmentwas excluded, not only because of the technical dif-ficulty caused by a hostile abdomen and the need toexplant the endograft but also because a laparotomywould have necessarily worsened the respiratoryimpairment and probably yielded to a severe respi-ratory distress syndrome. Endovascular repair wastherefore chosen, although the emergent settingleft no time to purchase the most suitable devices,and the repair had to be carried out with the stocksavailable in the hospital warehouse.Under general anesthesia, a microsurgical accesswas obtained at the right common femoral artery(CFA), whereas the left was approached percutane-ously. Introducers Cook 8  45 mm and Cook7  45 mm (Cook Medical Inc, Bloomington, Indi-ana) were placed in the left and right CFA, respec-tively. The right renal artery (RRA) was engagedfrom the left access with a 6F catheter. On the rightside, the introducer was switched with a Gore 18Fintroducer (Gore & Ass, Flagstaff, Arizona), and anangiogram was performed, showing aortic ruptureright above the left renal artery (LRA), which wasbarely visible (Fig. 4). Owing to the shrinkage ofthe left kidney, it was decided that the LRA couldbe sacrificed and only the RRA was revascularized.On a guide wire V18, two Viabahn 7  50 mmand 8  100 mm (Gore & Ass, Flagstaff, Arizona)were placed in the RRA. A Gore aortic cuff sized32  45 mm was placed right below the origin ofthe superior mesenteric artery (SMA) and deployedwith intentional covering of the LRA. The two Via-bahn (periscope technique) were then deployedand they were postdilated simultaneously with thecuff (Cordis OPTA Pro 7  100 [Cordis Corp.,Milpitas, CA] was used for the stent grafts andReliant [Medtronic Inc, Minneapolis, Minnesota]for the cuff). At the completion angiogram, com-plete exclusion of the aneurysm was observed,with patency of the SMA and RRA (Fig. 5). The pa-tient was extubated at the awakening and showedquick recovery of the vital parameters (BP: 105/60 mm Hg).RESULTSOn postoperative day 2, he performed a CTA thatshowed a type IA endoleak because of slight caudadmigration of the aortic cuff, with reduction of theretroperitoneal hematoma (Figs. 6 and 7). Reinter-vention was carried out, with surgical access at theright CFA and the left brachial artery. From thebrachial access, a Gore introducer 9 70 was placedat the origin of the SMA, which was engaged fromabove, and a covered stent (VBX 7  59 mm)(Gore &Ass, Flagstaff, Arizona) was inserted. Fromthe CFA access, a Gore endograft aortic cuff32  45 was placed right below the celiac trunk(CT) origin and deployed along with the SMA VBXafter safety engagement of the right renal Viabahn.Completion angiography showed absence of leakand patency of the CT, SMA, and RRA (Fig. 8).After awakening and extubation, the patient wasstable and in good clinical conditions and was trans-ferred to the internal medicine ward for an observa-tion period owing to the COVID-19 pneumonia,which showed a stepwise but constant recoveryduring the postoperative course (improvement ofthe lung translucency at the chest X-ray on postop-erative day 12 and drop of C-reactive protein to3.6 mg/dL).DISCUSSIONEndovascular repair of complex AAAs involving therenal arteries, whether with fenestrated, branchedendografts or parallel grafting, has been largely vali-dated in the latest years, and it has proven safe andeffective, provided that adequate surgical expertiseand suitable endovascular materials are available.2Those conditions still limit the feasibility of EVARof pararenal aneurysms in emergent settings, espe-cially in case of free-rupture and hemodynamicinstability, with little time for accurate planningand sizing and often lack of the optimal endograftsize.3 In those situations, open repair is still consid-ered the treatment of choice, despite the heavyburden of possible complications in a high-risk pa-tient, as in this case: in fact, open repair wouldTable I. Blood tests at the admittanceHb(g/dL)WBC(103/mL)PLT(103/mL) aPTT (sec) INRd-Dimer(ug/dL)CRP(mg/dL)IL-6(pg/mL)S-Cr(mg/dL)7.5 10.23 89 40.70 1.15 5,334 18.26 136.08 1.84Hb, hemoglobin; WBC, white blood cells; PLT, platelets; aPTT, activated partial thromboplastin time; INR, international normalizedratio; CRP, C-reactive protein; IL-6, interleukin-6; S-Cr, serum creatinine.Fig. 2. CTA scan: free ruptured AAA in the pararenalaortic tract with massive intraperitoneal hematoma (redarrow). AAA, abdominal aortic aneurysm; CTA,computed tomography angiography.Volume 66, July 2020 Case reports 20have required delayed conversion of the previousEVAR with an endograft explant, and the presenceof a left colostomy, midline laparocele, and intraper-itoneal hematoma would have made the access tothe aorta extremely difficult and time-consuming,with a considerable damage of the respiratorymech-anism and a prolonged condition of respiratorydistress. The patient was actually asymptomatic forrespiratory infection, but the imaging and labora-tory tests showed clear signs of a moderate-to-severe involvement of the pulmonary area andinitial signs of systemic involvement. Although nospecific indication has been given yet about themanagement of patients with COVID-19warrantingurgent aortic surgery, the consequences of laparot-omy on the respiratory system are well known,especially in already compromised patients, and sois the great advantage of EVAR over open aortic sur-gery in terms of pulmonary involvement4; there-fore, the advanced endovascular treatment wasthe most reasonable choice, even in absence of awide selection of endovascular materials coveringall possible sizes. Parallel grafting has already beendescribed in semiurgent, urgent, and even emergentsettings, with satisfactory outcomes, includinglower mortality and lower complication rate andshorter intensive care unit (ICU) stay, and its rolecan result even more precious now, to avoid opensurgery in patients with COVID-19.3 In this respect,the importance of having a wide variety of endovas-cular devices stored in the hospital warehouse iscrucial because it offers the possibility to treat safelymany and different types of aortic diseases andanatomic configurations, not only in urgency butalso in elective settings because supplies could bedelayed owing to the lockdown and other measuresto contain the viral spread.In the present case, a longer proximal neck couldhave been obtained by performing a chimney grafton the SMA from the beginning, which wouldhave spared the patients the second intervention,but the emergent conditions of the patients (hemor-rhagic shock with hemodynamic instability) made itpreferable to try for a quicker and less invasive treat-ment. That was in fact successful in excluding theaneurysm and stop the intraperitoneal hemorrhage,as demonstrated by the hemodynamic stabilizationand the CTA, and made it possible to perform thereintervention on a stable patient, in non-emergent setting. Although EVAR is at high riskfor late failure and complications, and despite beingtechnically demanding due to the parallel grafting,endovascular repair appears in those cases the treat-ment of choice, because it represents the safest andquickest way to stop the hemorrhage preservingthe respiratory function. In fact, not only did the pa-tient regain his consciousness and hemodynamicstability shortly after the end of the procedure, buthe was also extubated and has had no furtherneed for ventilatory support so far. Moreover, endo-vascular repair avoided postoperative ICU stay,which would have been necessary in case of openrepair, in a moment of dramatic shortage of bedsowing to the critically ill patients with COVID-19.The outbreak of COVID-19 in Northern Italy, infact, has imposed the conversion of many hospitals,including ours, into COVID-19ededicated centers,with only little resources available for theFig. 4. Preoperative angiogram. Fig. 5. Completion angiogram after the first interventionshowing patency of the RRA. RRA, right renal artery.Fig. 3. 3D volume rendering of the ruptured AAA. AAA, abdominal aortic aneurysm; 3D, three-dimensional.21 Case reports Annals of Vascular Surgerymanagement of other emergencies. Theoretically,non-COVID emergencies should be referred to othercenters, but often these patients cannot be safelytransferred, so it is of the utmost importance tohave a protocol for all those cases requiring nonde-ferrable treatment. The one followed in our centerconsists of early screening for COVID-19 throughnasal swab and chest X-ray for all patients accessingto the emergency room and separate routes forinhospital admission for patients with and withoutCOVID-19. The operatory theaters and the hospitalwards are also divided between patients with andwithout COVID-19. If COVID-19 positivity cannotbe determined before admission and surgery, thepatients is managed through the ‘‘clean’’ route butwith all precaution of staff individual protectionand room sanification that are used for patientswith COVID. In the present case, the result of thenasal swab was only available after the first inter-vention began, but the patient was consideredCOVID-19 positive since the beginning based onthe chest X-ray. All these considerations are crucialto contain the viral spread among inhospital patientsand were extremely helpful in choosing the mostsuitable approach of treatment.As acknowledged previously, the risk of failure ofemergent parallel grafting in ruptured AAAs is high,ranging between 10% and 26%, but the most com-mon complications of EVAR, namely endoleak, canbe addressed by endovascular treatment, whichFig. 8. Completion angiogram after the second interven-tion, showing aneurysm exclusion and patency of theSMA and the RRA. RRA, right renal artery; SMA, supe-rior mesenteric artery.Fig. 7. Angiogram showing contrast blushing at the levelof the left renal artery (red arrow).Fig. 6. CTA on postoperative day 2, showing a type IAendoleak (red arrow) and reduced intraperitoneal hema-toma. CTA, computed tomography angiography.Volume 66, July 2020 Case reports 22makes the risk of failure less worrisome than theperspective of an open conversion.5The last suggestion regarding the managementof patients with COVID-19 needing immediateaortic surgery regards anticoagulation: in fact,although the incidence of thrombotic events inthese patients is still unknown, an altered coagula-tion profile and an increased tendency to developmicrothromboses and macrothromboses in botharterial and venous system have been confirmedby several authors, so early anticoagulation withsystemic heparin administration should be startedin all these patients before starting endovascularprocedures.6,7CONCLUSIONSDespite being a single case report, this is to ourknowledge the first experience regarding emergentcomplex aortic surgery in a patient with COVID-19. The main suggestions that can be drawn fromthis regard are the benefits of endovascular surgery,even in absence of adequate materials, the impor-tance of keeping a well-supplied warehouse, andearly systemic anticoagulation before surgery. Min-imal invasiveness and prevention of the complica-tions, in fact, are the key to manage the vascularurgency and avoid progression of the infectionthat can evolve from pneumonia to multiorganfailure.None.REFERENCES1. Hu Y, Sun J, Dai Z, et al. Prevalence and severity of coronavirus disease 2019 (COVID-19): a systematic review andmeta-analysis. J Clin Virol 2020;127:104371.23 Case reports Annals of Vascular Surgery2. Katsargyris A, Oikonomou K, Klonaris C, et al. Comparison ofoutcomes with open, fenestrated, and chimney graft repair ofjuxtarenal aneurysms: are we ready for a paradigm shift? JEndovasc Ther 2013;20:159e69.3. Bin Jabr A, Lindblad B, Kristmundsson T, et al. Outcome ofvisceral chimney grafts after urgent endovascular repair ofcomplex aortic lesions. J Vasc Surg 2016;63:625e33.4. IMPROVE Trial Investigators. Endovascular strategy or openrepair for ruptured abdominal aortic aneurysm: one-year out-comes from the IMPROVE randomized trial. Eur Heart J2015;36:2061e9.5. Wilson A, Zhou A, Bachoo A, et al. Systematic review ofchimney and periscope grafts for endovascular aneurysmrepair. Br J Surg 2013;100:1557.6. Marone EM, Rinaldi LF. Upsurge of deep venous thrombosisin patients affected by COVID-19: preliminary data andpossible explanations. J Vasc Surg Venous Lymphat Disord2020 [Epub ahed of print].7. Zhai Z, Li C, Chen Y, et al. Prevention and treatment ofvenous thromboembolism associated with coronavirus dis-ease 2019 infection: a consensus statement before guidelines.Thromb Haemost 2020 [Epub ahead of print].

Endovascular Treatment of a Ruptured Pararenal Abdominal Aortic Aneurysm in a Patient With Coronavirus Disease-2019: Suggestions and Case Report

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Endovascular Treatment of a Ruptured Pararenal Abdominal Aortic Aneurysm in a Patient With Coronavirus Disease-2019: Suggestions and Case Report

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