Non-Surgical Pneumoperitoneum After Fenestrated Endovascular Aortic Repair- Case Report

ObjectivePost-operative pneumoperitoneum is mainly related to gastrointestinal perforation, although non-surgical pneumoperitoneum may also be present, with mechanical ventilation being the leading cause. Herein, we report a case of non-surgical pneumoperitoneum after percutaneous fenestrated endovascular aortic repair (fEVAR).Case reportA 79-year-old female presented with a 58 mm asymptomatic juxtarenal abdominal aortic aneurysm. The preoperative computed tomography angiography (CTA) detected also a diaphragmatic hernia. According to the latest guidelines, an indication for fEVAR was set. The successful implantation of a four-fenestrated custom-made endograft was performed using bilateral percutaneous femoral access. Even though the immediate postoperative period was uneventful, the predischarge CTA revealed a high-volume pneumoperitoneum and pneumomediastinum. The patient developed mild tenderness of the lower abdomen during palpation, and a postoperative elevation of the C-reactive protein (CRP = 205 mg/L) was identified. After general surgery consultation, an exploratory laparoscopy with intraoperative gastro-duodenoscopy were performed, which revealed no evidence of gastrointestinal perforation. The patient was discharged in good general condition on the sixth postoperative day.ConclusionPost-operative pneumoperitoneum may be related to mechanical ventilation due to alveolar injury after fEVAR. Laboratory and imaging findings should be judged in the influence of clinical image. An initial watch and wait approach may be justified.