COVID-19 Infection and Aneurysm Rupture in the Presence of Endoleak Post EVAR

The necessity for treatment of endoleaks after endovascular aortic aneurysm repair (EVAR), and the urgency of an additional procedure for endoleak treatment are still under discussion. The recommendations to aid this decision currently include factors like type of endoleak, aneurysm diameter progression, and anticoagulation therapy. This case report adds the co-factor of an active COVID-19 infection to the discussion of when and how to intervene for endoleaks after EVAR. A 72-year-old man presented in the outpatient clinic because of new onset of intermittent claudication 6 weeks prior. His medical history included standard EVAR 3 years and 4 months prior for asymptomatic abdominal aortic aneurysm. The patient discontinued follow-up at 3 months with a stable aneurysm. Magnetic resonance arteriography revealed an endoleak type III with major component dislocation and bilateral partial iliac artery obstruction. The patient was hospitalized immediately and diagnosed with active fresh COVID-19 infection (polymerase chain reaction [PCR]-positive). Due to the symptomatic active COVID-19 infection, open conversion surgery was considered too risky for the patient. During the evaluation for redoing EVAR, and waiting for materials, and with twice-repeated positive PCR COVID tests, the patient was found dead in the hospital bathroom on the morning of day 8 of the hospitalization. Autopsy confirmed free aneurysm rupture as cause of death. In the recent literature, increased rupture rates for AAA in patients with COVID-19 infections due to the inflammatory response are reported. This may also apply for patients post EVAR with evidence of endoleak, larger aneurysm diameter, and confirmed COVID-19 infection. A discussion is needed on the necessity for intensified follow-up and additional imaging in patients with endoleak post EVAR developing COVID-19 infection, and an adaptation of the treatment indication toward a more aggressive endoleak management is required.