Covered Stent for the Management of Perigraft Seroma after Hybrid Endovascular Treatment

Visceral artery reconstruction and extended endovascular aortic repair (EVAR) for thoraco-abdominal aortic aneurysm (TAAA) has been reported as less invasive therapy for TAAA. Perigraft seroma after this procedure is rare; however open repair for this complication is difficult. We repaired perigraft seroma by endovascular procedure with a handmade covered stent successfully. A 74-year-old female underwent ascending, arch and descending aortic aneurysmectomy at another institution in 2007. She developed pseudoaneurysm at the distal anastomosis and was referred to our hospital in 2011. She also had thoracoabdominal aneurysm with maximal diameter of 47 mm. Because of the previous thoracic surgery, a hybrid procedure was selected instead of open repair. Under general anesthesia, the terminal aorta, bilateral renal arteries (RAs), a superior mesenteric artery (SMA) and a celiac artery (CA) were exposed. Bypass graft between the terminal aorta and the SMA was constructed with a 12-mm Hemashield graft (MAQUET Cardiovascular LLC, NJ). Blood flow from the Hemashield graft to RAs and CA were constructed with polytetrafluoroethylene (PTFE) graft (W. L. Gore, Flagstaff, AZ). TAG stent grafts (W. L. Gore, Flagstaff, AZ) were deployed to seal the pseudoaneurysm and thoracoabdominal aortic aneurysm. Postoperative course was uneventful. However, three months after the procedure, she developed a perigraft seroma and it was drained by re-laparotomy. Three months after the second laparotomy, the seroma re-expanded to 52 mm diameter around the PTFE graft anastomosed to right renal artery. The seroma compressed the 3rd portion of duodenum and the Hemashield graft. Exchange the grafts responsible for the seroma would be very difficult because of previous operative findings, therefore endovascular treatment was planned. Prior to the procedure, unmounted Express^TM vascular LD stent (7 × 37 mm, Boston Scientific Corp., Natick, MA) was covered with great saphenous vein (GSV) and they were fixed with 4 of 6–0 prolene interrupted sutures. The covered stent remounted an Wanda^TM balloon catheter (5 × 40 mm, Boston Scientific Corp., Natick, MA). To prevent the covered stent slip drop from the balloon catheter during delivery, both ends of the balloon were slightly dilated and the covered stent was attached to the balloon firmly. A KTI sheath (18 F × 65 cm, Cook Medical Inc., Bloomington, Indiana) was used because of the enough length to reach the PTFE graft from common femoral artery, and the silicone pinch valve to minimalize blood loss. Under general anesthesia, covered stent was deployed in the PTFE graft to right RA. The perigraft seroma shrunk rapidly and the compression on both duodenum and Hemashield graft disappeared. Oral intake could be started 4 weeks after the procedure and she became well and discharged. The endovascular treatment seemed to be feasible and effective for perigraft seroma in high risk patients.