# Giant para-anastomotic aneurysms following open abdominal aortic surgery: Open surgery or endovascular management? Report of two cases and literature review

## TL;DR

This paper discusses two cases of giant para-anastomotic aneurysms and compares open surgery and endovascular treatments based on aneurysm location.

## Contribution

The paper presents two case reports and a literature review to compare treatment options for para-anastomotic aneurysms based on their anatomical location.

## Key findings

- FEVAR is effective for juxta-renal PAAs near the proximal anastomosis.
- Open repair is preferred for PAAs at the distal anastomosis due to fewer challenges from adjacent structures.
- Endovascular approaches avoid risks of open surgery like blood loss and splanchnic injury.

## Abstract

Para-anastomotic aneurysms (PAAs) represent a late complication of open surgical repair for occlusive or aneurysmal disease of the abdominal aorta. Due to limited literature and management challenges, we present two cases of PAAs and review existing evidence.

Case 1: A 66-year-old man with a history of open infrarenal aortic aneurysm repair presented with mild abdominal pain and a pulsatile mass. Computed tomographic angiography (CTA) showed a juxta-renal PAA near the prior proximal anastomosis. The pseudoaneurysm was managed through fenestrated endovascular aortic aneurysm repair (FEVAR) with four fenestrations.Case 2: A 76-year-old man with a history of open repair for aortic occlusive disease presented with chronic abdominal pain. CTA revealed two PAAs at the distal anastomosis of the prior aortoiliac graft. The patient underwent open repair surgery.

Case 1: A 66-year-old man with a history of open infrarenal aortic aneurysm repair presented with mild abdominal pain and a pulsatile mass. Computed tomographic angiography (CTA) showed a juxta-renal PAA near the prior proximal anastomosis. The pseudoaneurysm was managed through fenestrated endovascular aortic aneurysm repair (FEVAR) with four fenestrations.

Case 2: A 76-year-old man with a history of open repair for aortic occlusive disease presented with chronic abdominal pain. CTA revealed two PAAs at the distal anastomosis of the prior aortoiliac graft. The patient underwent open repair surgery.

The FEVAR approach avoids redo laparotomy, reducing risks of blood loss, and splanchnic injury. However, prior open repair requires careful endograft design, considering the graft's configuration, reduced compliance, and altered visceral anatomy. For distal anastomotic aneurysms, open repair was chosen due to fewer challenges from adjacent structures.

Based on our experience, FEVAR is effective for juxta-renal PAAs near the proximal anastomosis, while open repair is preferred for PAAs at the distal anastomosis. Further large-scale, long-term studies comparing these treatments are warranted.

•Para-anastomotic aneurysms are a late complication of open surgical repair for abdominal aortic diseases.•The surgical management of para-anastomotic aneurysms is equivocal and influenced primarily by their location.•Open repair surgery is one treatment option, though it is technically demanding due to previous surgery.•EVAR, CHEVAR, & FEVAR offer minimally invasive options when anatomy allows, expanding treatment choices.•FEVAR is effective for juxta-renal PAAs near the proximal anastomosis; open repair is preferred for distal anastomosis.

Para-anastomotic aneurysms are a late complication of open surgical repair for abdominal aortic diseases.

The surgical management of para-anastomotic aneurysms is equivocal and influenced primarily by their location.

Open repair surgery is one treatment option, though it is technically demanding due to previous surgery.

EVAR, CHEVAR, & FEVAR offer minimally invasive options when anatomy allows, expanding treatment choices.

FEVAR is effective for juxta-renal PAAs near the proximal anastomosis; open repair is preferred for distal anastomosis.