We report a case of a patient with a residual hematoma compressing the inferior vena cava after endovascular aneurysm repair (EVAR), which led to a pulmonary embolism (PE). A 65-year-old man underwent emergent EVAR for a ruptured aortic aneurysm in the right retroperitoneal region. He developed sudden chest pain at midnight of the fifth day after EVAR, and computed tomography demonstrated a massive PE. He subsequently went into cardiopulmonary arrest. This case suggested that abdominal complications due to a residual hematoma, including deep vein thrombosis and PE, should be considered in addition to compartment syndrome.
The results of some reports support the benefits of endovascular aneurysm repair (EVAR) compared with those of open surgical repair (OSR) for managing a ruptured abdominal aortic aneurysm (rAAA) [
A 65-year-old man was admitted to our emergency department because of sudden back pain and hypotension (systolic blood pressure, 80 mmHg). Unmedicated hypertension was noted at the time of admission. He had no signs of deep vein thrombosis (DVT) in his legs, such as obvious edema. Enhanced computed tomography (CT) demonstrated the presence of an rAAA, measuring 7.9 × 7.6 cm in diameter, in the right retroperitoneal region (Figure
(a) Enhanced computed tomography revealing a ruptured aortic aneurysm measuring 7.9 × 7.6 cm in diameter in the right retroperitoneal region. (b) The inferior vena cava is compressed by a hematoma (black arrow).
Angiogram before (a) and after (b) endovascular aneurysm repair.
Echocardiography revealed right ventricular dysfunction, and CT revealed a massive pulmonary embolism (Figure
Enhanced computed tomography revealing a pulmonary embolism (white arrow).
The use of EVAR for rAAA remains limited by the risk of abdominal compartment syndrome and residual hematomas. There are some published reports of large aneurysms compressing the IVC and inducing venous thromboembolisms [
This case highlights the importance of complications due to a residual hematoma after EVAR for an rAAA. de Maistre et al. [
In the present case, the initial physical examination revealed no signs of a venous thromboembolism. After EVAR, slight edema was observed which affected the entire body and not just the legs. We considered this edema to be due to the large volume of transfusion. Furthermore, we did not use an anticoagulant to prevent DVT because of the risk of postoperative hemorrhage from an endoleak. Although CT revealed no obvious sign of a venous thromboembolism at 3 days after EVAR, the main indication for CT at this time was to look for a potential endoleak. Therefore, CT of the leg was not performed. Echography of the inguinal region and legs may have been useful.
In conclusion, after EVAR for rAAAs, clinicians should consider abdominal complications due to a residual hematoma, including DVT and a PE, in addition to compartment syndrome. Although EVAR is less invasive in patients with favorable anatomy, it is limited by an inability to remove hematomas in cases of rAAAs. Residual hematomas, particularly when located on the right side, may be a cause of DVT. Therefore, strict surveillance is required after EVAR for rAAAs. Furthermore, if necessary, the placement of a prophylactic IVC filter or secondary open conversion to remove the hematoma should be considered.
Takao Ohki is a consultant for W. L. Gore & Associates. The other authors declare that there are no conflicts of interest regarding the publication of this paper.
The authors would like to thank Enago (