key: cord-0847092-f87yct0g
authors: Rinaldi, Luigi Federico; Marazzi, Giulia; Marone, Enrico Maria
title: Endovascular treatment of a ruptured pararenal abdominal aortic aneurysm in a COVID-19 patient: suggestions and case report
date: 2020-05-15
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2020.05.011
sha: 1104a42f5298f3d358981b8b41eb911fb61b56a7
doc_id: 847092
cord_uid: f87yct0g

The aim of this report is to discuss emergent repair for complex aortic diseases in patients affected by novel coronavirus pneumonia (COVID-19), describing a case of ruptured pararenal aortic aneurysm. A COVID-19, eighty-years-old man 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 COVID-19 patients, despite the risk of late endoleak.

aneurysm (AAA) is to offer some consideration on this matter from the standpoint of a hub Hospital 50 for COVID-19 patients in Lombardy, the Italian region that has been affected the most by the 51 pandemics. showing a free rupture of the pararenal abdominal aorta, right above the previous endograft at the 67 level of the renal arteries, and a massive intraperitoneal hematoma (figg.2,3). Open surgical 68 treatment was excluded, not only due to the technical difficulty caused by a hostile abdomen and 69 the need to explant the endograft, but also because a laparotomy would have necessarily worsened 70 the respiratory impairment and probably yielded to a severe respiratory distress syndrome (ARDS). On post-operative day II, he performed a CTA showed a type IA endoleak due to slight caudad 95 migration of the aortic cuff, with reduction of the retroperitoneal hematoma (figg.6,7). 96

Reintervention was carried out, with surgical access at the right CFA and the left brachial artery. 97

From the brachial access, a Gore introducer 9x70 was placed at the origin of the SMA, which was 98 engaged from above, and a covered stent (VBX 7x59 mm) ® (Gore &Ass, Flagstaff, Arizona, US) 99 was inserted. From the CFA access, a Gore ® endograft aortic cuff 32x45 was placed right below the Theoretically, non-COVID urgencies should be referred to other centers, but often these patients 155 cannot be safely transferred, so it is of the utmost importance to have a protocol for all those cases 156 requiring non-deferrable treatment. The one followed in our Center consists in early screening for 157 COVID-19 through nasal swab and chest X-ray for all patients accessing to the Emergency Room 158 (ER), and separate routes for in-hospital admission for COVID and non-COVID patients. The 159 operatory theaters and the hospital wards are also divided between COVID-free and COVID-19 160 patients. If COVID-19 positivity cannot be determined before admission and surgery, the patients is 161 managed through the "clean" route, but with all precaution of staff individual protection and room 162 sanification that are employed for COVID-patients. In the present case, the result of the nasal swab 163 was only available after the first intervention began, but the patient was considered COVID-19 164 positive since the beginning based on the chest X-ray. All these considerations are crucial to contain 165 the viral spread among in-hospital patients and were extremely helpful in choosing the most 166 suitable approach of treatment. 167

As acknowledged above, the risk of failure of emergent parallel grafting in ruptured AAAs is high, 168 ranging between 10% and 26%, but the most common complications of EVAR, namely endoleak, 

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