Recurrent aneurysm 11 years after thoracoabdominal aortic replacement due to recanalization of intercostal arteries of the wrapping native aorta in Marfan syndrome: a case report

Persistent blood flow is common in aortic aneurysms following endovascular repair. However, the recanalization of thrombosed intercostal arteries after open aortic repair is rare. We report a case of aortic aneurysm recurrence 11 years after thoracoabdominal aortic replacement resulting from recanalization of the intercostal arteries like a type II endoleak in a patient with Marfan syndrome. A 50-year-old woman with Marfan syndrome presented with left-sided back pain after meals. She underwent abdominal aortic replacement at 35 years of age, distal aortic arch and thoracoabdominal aortic replacement for type B chronic aortic dissection at 38 years of age, and aortic root to the remnant arch replacement with a mechanical valve conduit for type A acute aortic dissection at 43 years of age, which resulted in complete replacement of the entire aorta with prosthetic grafts. The patient has been taking warfarin since then. The prothrombin time-international normalized ratio levels were controlled almost within the range of 1.5-2.5 during the follow-up period, but it was elevated up to 3.4 at 1 month before she felt back pain and kept high at 4.2 on admission. Enhanced computed tomography (CT) revealed an aneurysm between the descending graft and the remaining native aortic wall, compressing the esophagus. However, there were no abnormal findings on the CT performed 10 months prior to admission. Surgery revealed that the orifices of the intercostal arteries were patent with backflow. We closed the patent intercostal arteries using nonabsorbable sutures. The patient's postoperative course was uneventful, and the CT performed 1 year later showed no aneurysmal recurrence. Here, we describe a rare case of recurrent aortic aneurysm long term after graft replacement due to recanalization of the intercostal arteries of the remaining aortic wall. Our findings suggest that closing all orifices of the intercostal arteries during aortic repair, regardless of backflow, could prevent delayed reopening; systemic anticoagulation after aortic replacement may be a risk factor for recanalization, and that postoperative periodic CT follow-up is essential, especially in patients receiving anticoagulant therapy.