Complex Aorto-Spinal Fistula With Multifocal Abscesses in an Immunosuppressed Elderly Man Following Endovascular Aortic Repair

BACKGROUND Endovascular aneurysm repair (EVAR) effectively treats abdominal aortic aneurysms but risks complications, including endoleak and graft infection. CASE REPORT A 74-year-old man with EVAR, complicated by endoleak the following month with persistent pain following endoleak repair, presented with multiple abscesses (epidural, psoas, and disc space) and an aorto-disc fistula 7 months after the endoleak repair. Long-term corticosteroid use and an interleukin-6 inhibitor for presumed polymyalgia rheumatica contributed to immunosuppression. This misdiagnosis, along with immunosuppression and inconclusive outside imaging, diagnostic tunneling contributed to a delayed diagnosis until discitis, osteomyelitis, and abscesses were discovered on computed tomography (CT). This case is a rare presentation, and there is scant literature on spinal abscess from EVAR. Given the uniqueness and complexity of the presentation, a multidisciplinary approach was required for a better outcome, including multiple surgery teams and multiple medical teams. Management included abscess drainage, EVAR explant with rifampin-soaked Dacron graft reconstruction, surgical debridement, antibiotic beads, and 6 weeks of intravenous daptomycin for coverage of previously positive spinal tissue cultures (methicillin-sensitive Staphylococcus aureus and Cutibacterium acnes) with a plan for lifelong suppression with doxycycline. The patient ultimately had a new endoleak requiring repair, but was doing well as of his last appointment 8 months after his presentation to our facility. CONCLUSIONS This case demonstrates the need for postoperative vigilance and multidisciplinary care for patients undergoing EVAR. Comprehensive source control and close follow-up have thus far yielded a successful clinical outcome.