The emergency medicine approach to abdominal vascular graft complications

Abdominal aortic aneurysm (AAA) is a deadly condition, particularly with rupture. Emergency physicians provide vital frontline care to the diagnosis and treatment of this disease. Endovascular aortic repair (EVAR) has become the gold standard for treatment of AAA, but the management of EVAR complications is not well discussed in the emergency medicine literature.

The purpose of this article is to provide an emergency medicine-focused review of the complications of EVAR.

Although many complications may arise after AAA repair, the most common include aortoenteric fistula, endoleak, limb ischemia, and graft infection. All potential complications should receive vascular surgery consultation and hemodynamic resuscitation. Aortoenteric fistula often presents nonspecifically with gastrointestinal (GI) bleeding, abdominal pain, and vomiting. Computed tomography with intravenous contrast is required for diagnosis. An endoleak is defined by vascular flow outside of the graft. The optimal diagnostic modality includes triple phase computed tomographic scan (noncontrast, arterial, delayed phase). Limb ischemia may occur before 2 months, or in a later period, with symptoms ranging from claudication to complete neurovascular compromise. Graft infection is most commonly due to Staphylococcus aureus, and imaging can suggest the diagnosis. Definitive diagnosis requires tissue or fluid sampling. Through an understanding of these complications, emergency physicians may improve patient outcomes.

With the growing use of EVAR, emergency physician exposure to complications of this procedure is increasing. Knowledge of the complication presentations, diagnoses, and management can play an integral role patient care.