Co-existence of Abdominal Aortic Aneurysm with Urologic Neoplasm: Which Should Be Treated First in the Endovascular...

Prevalence of Abdominal Aortic Aneurysm (AAA) with concomitant malignancy rounds 3-13%. Considering only urological neoplasms the prevalence is around 3.6%. Survival at 5 years of bladder carcinoma without extravesical invasion (stage II) rounds 63%. Endovascular Aneurysm Repair (EVAR), due to its minimally invasive profile, is an option for treatment of AAA prior to urological surgery as it does not require laparotomy not conditioning the delay of oncologic surgery.

Male, 62 years old. History of smoking and coronary artery disease and urothelial carcinoma of the bladder (T2N0M0). In the abdominal CT scan used for neoplasm staging a para-renal AAA with 50 mm of maximum diameter was firstly detected. This aneurysm presented only 5 mm of proximal neck length, insufficient for a safe proximal sealing with standard endografts. In consequence the treatment of choice was a tetra-fenestrated endograft (F-EVAR).

F-EVAR occurred without complications: no endoleaks, access complications or branch thrombosis. Three months after F-EVAR, the patient underwent radical cystectomy with jejunocystoplasty, which also occurred without intercurrences. Two days after FEVAR patient was discharged home. After one year of follow-up, abdominal CT scan did not reveal any complications related to the endovascular procedure. The patient died 18 months after the intervention as a consequence of metastatic evolution of bladder primary neoplasm.

The coexistence of AAA with neoplastic urologic pathology although rare is not negligible. In the above case, the patient presented AAA with about 5 cm (1-11% risk of rupture per year), associated with T2N0M0 bladder urothelial carcinoma (survival at around 63% at 5 years). Given the need for treatment of both pathologies, the doubt persisted about which procedure should be performed first: aneurysm repair or cystectomy. Prior to the advent of EVAR, AAA repair would require laparotomy with a potentially greater risk of complications in the subsequent urologic procedure, prosthesis infection and significant delay of the cystectomy. With the emergence of endovascular techniques, AAA repair occurs without conditioning postponement or significant complications during a subsequent urological procedure and then "EVAR first" was the decision. Two days after FEVAR patient was discharged home and three months latter cystectomy was performed also without complications.

in case of concomitant AAA and abdominal malignancy balance between risk of rupture and progression of the neoplastic disease need to be weighted. With the advent of endovascular disease EVAR prior to the oncologic surgery represents an efficient, prompt and safe solution.