Infrarenal aortic aneurysm in a patient with remote history of liver transplant with aorto-hepatic conduit

A 72-year-old male with a past medical history of hypertension, peripheral artery disease, and cadaveric liver transplant twenty-seven years prior for hepatitis C induced liver failure was found to have an asymptomatic ten cm infrarenal abdominal aortic aneurysm (AAA) during a CT scan for evaluation of genitourinary symptoms (Image A , Video 1). Notably, the Dacron aorto-hepatic conduit used for the transplant came off mid-aneurysm, making any method of repair especially challenging (Image B/Cover). An endovascular approach was chosen due to patient comorbidities and patient choice. Due to the location of the aorto-hepatic conduit, the decision was made to proceed with a single-branch, physician-modified endograft on the Terumo Treo platform (Terumo Aortic, Sunrise, FL). An 8x75mm self-expanding Viabahn covered stent was deployed into the Dacron aorto-hepatic conduit and this was bridged to the main graft with an 8x59mm Viabahn VBX balloon-expandable covered stent (W.L Gore and Assoc., Newark, DE). Completion aortography demonstrated successful deployment of the stent graft system with brisk filling of the aorto-hepatic conduit and no evidence of endoleak (Image C). The patient's postoperative course was uneventful, getting discharged on post-operative day one. A follow-up CT angiography was performed one month postoperatively that demonstrated successful endovascular stent graft placement with no evidence endoleak (Image D, Video 2). He continues to be well, now six months post-operatively. Abdominal aortic aneurysms are more common in organ transplant patients and present distinct challenges given their complex cardiovascular comorbidities, limited collateral circulation with an increased risk of necrosis, and adhesions from transplant surgery.2Premaratne S. Hopkins J. Duddy M. et al.Abdominal Aortic Aneurysm Repair in Renal and Liver Transplant Recipients.Vascular and Endovascular Surgery. 2020; 54: 51-57https://doi.org/10.1177/1538574419880673Crossref Scopus (2) Google Scholar The current recommendation for AAA repair in liver transplant patients is to use EVAR, especially with patients at high risk for an open repair.3Brewster D.C, Cronenwett J.L, Hallett J.W, Johnston K.W, Krupski W.C, Matsumara J.S. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery.Google Scholar However, the use of commercially available devices is limited in certain cases due to anatomic constraints. This unique case demonstrates the use of a single branch physician-modified endograft to repair an aneurysm involving an aorto-hepatic conduit originating from the infrarenal abdominal aorta. Informed consent was obtained for the publication of this report and the accompanying images. No funding was provided. 1Salimi J. Jafarian A. Behzadi M. Nejat A. Fakhar N. Endovascular abdominal aortic aneurysm repair in a patient with previous history of simultaneous orthotopic liver kidney transplantation.J Surg Case Rep. 2021 Aug 24; 2021 (PMID: 34434541; PMCID: PMC8382315)rjab332https://doi.org/10.1093/jscr/rjab332Crossref Scopus (1) Google Scholar; 1.. The authors have no competing interests. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2NjA3ODdkMjEyYTljOGI1MzZjODNkMjlhMGEwMTdhNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzE0ODkyOTM3fQ.H7ZRVzvgse8dogp8TxfA9v2C6qfJWMpWuj2N5Jf9FfN4hwws5grdK3EGOk2kmOWxFjWUhYC4mZMuasmfLwlvKukUCEpyZ6ni2n1lasydmWXO4qNBLbVk_-bwopuPslVoFdaybcT4JO9mtq0De82teAQzrhWn23kB0bafuy1JZUAwsyaIa1U2uDmOHSl0DGC68hoTXDgxMhVLgtzU9tZ1DmNLUhJVuUWdbPEzl_BwOFJzsLZaC_m10t0SnJ5_YfWZ93WnI-mMjwlLfPxvxq3w-nbjNC6TVGeL4AVk3_I0pa-fFIOq8ly0GZtIGAtglOe4e4qu6K-IChovNVgALcA57w Download .mp4 (2.09 MB) Help with .mp4 files eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhOGI3MjM5MDJjY2Q4M2UzMmMxYTUyNzJlNzFjZTk1ZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzE0ODkyOTM3fQ.ava7Vm0Y8W7PDuD9FevjDtjoJdVj73jl7IPsDHtdA4JhatmIakyIj4tmr-NayQ7HVCh56dVJEXb8jt1uxASpWh7NL81nycCkmKTtDrGVs1j25gqvMTcHr-B6KexiYGuFaXeOcFhJrPQAH7-C0tNK0CTbbKYCo6ii20QKRMJ8fzuuUD7oQsew_99yJAVzLS6pQ1cftI1NBUFMR1N6Eo7u11IxzPUI7l3mXyCfyKpLrcno49ZWAx7WwKtXU_1XONkg9vhnxP1u635by4Jxop8HNDW-iKPqrS0reSggnZajrhGmLDL72MMpVn6RowGn7qhX863_v2dBOEtuVxYJfTypXQ Download .mp4 (4.21 MB) Help with .mp4 files