Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 329-330

Systemic inflammatory response and delayed thrombocytopenia following endovascular aneurysm repair for abdominal aortic aneurysm


Consultant Vascular Surgeon, Kauvery Hospitals, Salem, Tamil Nadu, India

Date of Submission31-Jan-2022
Date of Acceptance21-Feb-2022
Date of Web Publication8-Nov-2022

Correspondence Address:
Karthikeyan Sivagnanam
Consultant Vascular Surgeon, Kauvery Hospitals, Salem, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_7_22

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  Abstract 


Postimplantation syndrome following endovascular aneurysm repair (EVAR) is a known entity which presents within the 1st week of EVAR. The symptoms include fever, leukocytosis, and elevated C-reactive protein. Although the pathogenesis is unknown, it resolves within a 5 days. This case report involves elaborating on delayed onset inflammatory response in the 3rd week following EVAR when the patient developed thrombocytopenia which went as low as 55,000/μL. It resolved gradually with supportive measures and systemic steroids.

Keywords: Endovascular aneurysm repair, postimplantation syndrome, thrombocytopenia following endovascular aneurysm repair


How to cite this article:
Sivagnanam K. Systemic inflammatory response and delayed thrombocytopenia following endovascular aneurysm repair for abdominal aortic aneurysm. Indian J Vasc Endovasc Surg 2022;9:329-30

How to cite this URL:
Sivagnanam K. Systemic inflammatory response and delayed thrombocytopenia following endovascular aneurysm repair for abdominal aortic aneurysm. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Nov 28];9:329-30. Available from: https://www.indjvascsurg.org/text.asp?2022/9/4/329/360549




  Introduction Top


Aortic aneurysms are a relatively common disease that can lead to potentially fatal consequences. Endovascular repair of aortic aneurysms (EVARs) is a minimally invasive surgery for their treatment, presenting many advantages over open repair.[1],[2] After the correction of aortic aneurysm by EVAR, a systemic inflammatory response, named postimplantation syndrome (PIS), can develop, is characterized by fever, leukocytosis, and elevated C-reactive protein (CRP) plasma levels.[3],[4],[5],[6] We describe the case of a male patient who developed delayed postimplantation inflammatory syndrome characterized by thrombocytopenia after endovascular repair of infrarenal aortic aneurysm.


  Case Report Top


An 82-year-old male underwent an elective EVAR for infrarenal abdominal aortic aneurysm (AAA) of 6.5 cm diameter. He was on regular surveillance for 4 years before undergoing the procedure. His medical conditions include long years of Type 2 diabetes mellitus, hypertension, early-stage chronic kidney disease with serum creatinine of 1.8 mg/dl, and benign prostate enlargement.

During the evaluation, his computed tomography (CT) angiogram showed an infrarenal aortic aneurysm with a good length neck and significant thrombus load in the aneurysm sac. He underwent EVAR with Zenith Flex® AAA Endovascular Graft Bifurcated Main Body Graft.

In the first 72 h following EVAR, he had a mild increase in serum creatinine, leukocytosis which increased up to white blood cells (WBC) – 18,000/μL and elevated CRP levels consistent with systemic inflammatory response. He also had a fever on the 2nd postoperative day which was treated with supportive measures. He developed urinary tract infection following the removal of his Foley catheter which was inserted for the procedure. The Foley catheter was removed on the 3rd postoperative day after he mobilized well. He was managed with piperacillin/tazobactam and switched orally to cefuroxime based on antibiotic sensitivity.

Following the discharge on the 7th postoperative day, his complete blood counts were repeated in the 2nd week which revealed normal levels. During the 3rd postoperative week, he again developed fever for which he was managed as in patient. His repeat blood parameters showed normal WBC count with thrombocytopenia which was hovering between 55,000/μL and 65,000/μL for a week. He gradually improved after a week of hospitalization and was discharged later. Post-EVAR, CT angiogram was also done during this admission which showed the appropriate placement of the EVAR graft with minimal Type 2 endoleak. The sac size had decreased by 1 cm.


  Discussion Top


EVAR is a minimally invasive surgery for AAA treatment, presenting many advantages over open repair.[1],[2] After the correction of aortic aneurysm by EVAR, a systemic inflammatory response, named PIS, can develop, is characterized by fever, leukocytosis, and elevated CRP plasma levels.[3],[4],[5],[6] PIS is a relatively common complication after the endovascular repair of aortic aneurysm with an incidence of 3%–60% for AAA.

The clinical manifestations of PIS could be considered as a systemic inflammatory response syndrome (SIRS) since PIS fulfills at least two criteria of SIRS, in accordance with the International Sepsis Definitions Conference.[6] PIS after EVAR is generally well tolerated, resolving within 5 days without any serious consequence. However, some patients develop a severe inflammatory reaction after EVAR which could persist during the 1st month. This condition may lead to mild or severe SIRS state, possibly causing severe complications, such as pulmonary dysfunction, cardiovascular events, renal insufficiency, and multiple organ failure.[1],[2],[4] The lack of a well-recognized pathogenesis of PIS hampers a specific pharmacological treatment, although as for SIRS, the use of nonsteroidal anti-inflammatory drugs in mild forms and of corticosteroids in severe forms has been suggested together with intensive care assistance.[1],[2],[4]

In conclusion, patients undergoing EVAR should be monitored for PIS and followed with inflammatory parameters including WBC count and platelet counts.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arnaoutoglou E, Papas N, Milionis H, Kouvelos G, Koulouras V, Matsagkas MI. Post-implantation syndrome after endovascular repair of aortic aneurysms: Need for postdischarge surveillance. Interact Cardiovasc Thorac Surg 2010;11:449-54.  Back to cited text no. 1
    
2.
Arnaoutoglou E, Kouvelos G, Papa N, Kallinteri A, Milionis H, Koulouras V, et al. Prospective evaluation of post-implantation inflammatory response after EVAR for AAA: Influence on patients' 30 day outcome. Eur J Vasc Endovasc Surg 2015;49:175-83.  Back to cited text no. 2
    
3.
Blum U, Voshage G, Lammer J, Beyersdorf F, Töllner D, Kretschmer G, et al. Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms. N Engl J Med 1997;336:13-20.  Back to cited text no. 3
    
4.
Akowuah E, Wilde P, Angelini G, Bryan AJ. Systemic inflammatory response after endoluminal stenting of the descending thoracic aorta. Interact Cardiovasc Thorac Surg 2007;6:741-3.  Back to cited text no. 4
    
5.
Velázquez OC, Carpenter JP, Baum RA, Barker CF, Golden M, Criado F, et al. Perigraft air, fever, and leukocytosis after endovascular repair of abdominal aortic aneurysms. Am J Surg 1999;178:185-9.  Back to cited text no. 5
    
6.
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Intensive Care Med 2003;29:530-8.  Back to cited text no. 6
    




 

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