Case Report: Emergency endovascular management of a ruptured giant abdominal aortic aneurysm with severely angulated and conical shaped neck using novel multiple stiff wire technique.

Background: Ruptured abdominal aortic aneurysm (rAAA) is commonly fatal, with an overall mortality rate of nearly 90%, and the risk of subsequent rupture remains high, especially in large aneurysm diameters or progressive disease. Unfavorable neck anatomy in EVAR is linked to early graft failure and long-term complications. Recently, a novel multiple stiff wire (MSW) technique has been developed to overcome the challenges of hostile neck anatomy without introducing additional devices and procedural complexity. It has also been feasible in a series of elective cases. In this case, we report the first-ever utilization of the MSW technique in an emergency case of an acute contained rAAA with a conical-shaped, severely angulated neck who underwent Endovascular Aortic Repair (EVAR). Case presentation: A 61-year-old man came with intermittent sharp stomach pain radiating to his back since three weeks ago. Physical examination showed elevated blood pressure and anemic conjunctiva. Laboratory examinations showed anemia, leukocytosis, elevated D-dimer level, high creatinine level, and low eGFR. CT-Scan Angiography (CTA) revealed severely hostile anatomy, a conical-shaped abdominal aorta aneurysm with a length of 13.2 cm and a maximum diameter of 9.3 cm with angulation of 90.1°. The patient was diagnosed with Ruptured AAA with a conical-shaped, severely angulated neck. Endovascular Aortic Repair (EVAR) management with MSW technique was planned for him. After four days, The patient was discharged in a clinically stable condition with optimal medical treatment and education. Conclusion: The endovascular approach could be performed in emergency settings and has been proven to reduce length of stay, mortality, and morbidity rates. In this case, the endovascular approach with the MSW technique showed promising results for the patient.