Rare and fatal late-term complication of endovascular aneurysm repair: Migration of the endograft into the duodenum.

Endovascular aneurysm repair (EVAR) is a treatment method that has become increasingly popular for abdominal aortic aneurysms (AAA) due to its ease of application, reduced hospital stay, and its suitability as an alternative for patients who cannot tolerate open surgery. Although the early outcomes of EVAR are better than those of open surgery, complications such as endoleak, migration, thrombosis or kinking of the endograft limbs, graft infection, and secondary rupture may occur. In this study, we present a patient who underwent EVAR at another institution approximately 10 years earlier and was admitted to our clinic with complaints of deterioration in general condition, fever, and melena. Laboratory examination of 73-year-old man revealed a white blood cell (WBC) count of 17,100, hemoglobin level of 9.5 g/dL, and C-reactive protein (CRP) level of 261 g/L. Computed tomography (CT) revealed thrombosis within the EVAR graft, free air surrounding the graft, fractures in the graft stents, and displacement of the right limb beyond the aorta at the level of the iliac bifurcation. The endograft was observed to have migrated toward the duodenum and formed a fistula. The pa-tient, who presented with sepsis, underwent emergency surgery. Initially, a left axillofemoral bypass was performed to relieve ischemia in the left leg. Subsequently, a laparotomy was performed with the joint participation of the general surgery and cardiovascular surgery departments. Intra-abdominal fecal contamination and rupture of the sigmoid colon were observed. The abdomen was lavaged, the sigmoid colon and rectum were excised, and a colostomy was created. An aortotomy was then performed, and the main body of the graft and its left limb were removed. The duodenum was opened, and the fistulized right limb of the endograft was also removed. No additional vascular intervention was required due to abdominal contamination, adequate collateral circulation in the right leg, likely due to the chronic nature of the process, and the absence of ischemia. The aorta was ligated at the infrarenal level, and the patient, who required high-dose inotropic support, was transferred to the intensive care unit. The patient died in the eighth postoperative hour. To our knowledge, this case represents a rare and unique complication that has not been previously reported in the literature. By presenting this case, we aim to draw attention to the long-term complications of EVAR and emphasize the importance of open surgery in patients with a high life expectancy.