A 40 year old female, diagnosed with SLE at age 24 years was referred with an asymptomatic pulsatile epigastric mass. Computed tomography aortogram (CTA) showed a 5.3 cm infrarenal right sided saccular aneurysm, 4 cm inferior to the origin of the left renal artery with an eccentric rind of mural thrombus and no suggestion of aortitis. Atherosclerotic calcification was noted within (Fig. 1).
The patient first presented with malar rash and lower limb swelling secondary to lupus nephritis, developing end stage renal failure at 27 years necessitating haemodialysis. Autoimmune panel was positive for anti-nuclear antibody, ENA, anti-Smith, anti-RNP, anti-Ro, anti-double stranded DNA, and anti-cardiolipin IgG. In addition, she suffered from chronic haemolytic anaemia, hypertension, dyslipidaemia, and coronary arterial disease. She had been on various anti-hypertensives, statins, immunosuppressant and disease modifying anti-rheumatic drugs including cyclophosphamide, prednisolone, azathioprine, and mycophenolate mofetil, with multiple admissions for drug related complications including thrombocytopaenia and osteoporosis from 24 years of age up to peri-operatively.
Serum C-reactive protein and erythrocyte sedimentation ratio were not elevated and blood cultures were negative although these may have been influenced by the use of immunosuppressants. Retrospectively, it was noted that a 4.3 cm infrarenal AAA was present 3 years previously during an ultrasonographic evaluation of her kidneys although she was not referred at that time.
A choice of open or EVAR was offered considering her age, and EVAR was chosen given the expected shorter length of stay, avoidance of laparotomy and its associated morbidities including increased pain, adhesions, incisional hernias, while bearing in mind risks of device failure, continued neck dilatation, and need for lifelong surveillance with EVAR.
The Medtronic Endurant II bifurcated stent graft (Medtronic International Ltd, Nasaco Tech Centre, Singapore) was inserted under local anaesthesia with mild sedation. The main body (ETBF 23-13c124 EE) was delivered via the right groin and the contralateral limb (ETLW 16-13c 82EE) through the left after ultrasound guided access. Operative time was 75 minutes and 160 mL of half strength contrast was used (Fig. 2A and B). Closure was achieved using the Abbott Perclose Proglide suture mediated closure system.
The patient was discharged well on the third post-operative day. CTA performed at 1 and 6 months post-EVAR (Fig. 3) and contrast enhanced ultrasonography at 2 years showed that the graft continues to exclude the sac satisfactorily.