A Successful Repair of a Giant Abdominal Aortic Aneurism.

Abstract

Dear Editor, We report a case of 15.4 cm abdominal aorta aneurysm, which underwent an emergent open repair. Our patient is a 64-year-old female, with past medical history of Type 2 di- abetes, hypertension and hyperlipidemia who presented to the emergency department with a two-day history of constant progressively worsening abdominal pain. Phys- ical exam was remarkable for a distended abdomen with pulsatile tender mass in the right peri-umbilical region. CT abdomen and pelvis with contrast showed a fusiform tortuous abdominal aortic aneurysm immedi- ately distal to the renal artery ostia at the level of the L1 vertebrae measuring 1.8 cm with extension into the bilat- eral common iliac arteries at the level of the bifurcation with sparing of the celiac and SMA (Figure 1). The patient was relatively healthy, but had stopped her hypertensive medications for the last year due to monetary issues and had no cardiac workup upon admission. The patient's transesophageal echocardiography (TEE) showed LVEF of 60% - 65%, PASP 35 - 40 mmHg, mild MR and TR with no wall motion abnormalities. Cardiology was consulted for risk stratification where she was declared to be low risk for a high-risk procedure. Patient was observed overnight in the intensive care unit and surgery was planned for the following morning. In the operating room, standard ASA monitors were applied. A left axillary arterial line for invasive monitor- ing of blood pressure and a right internal jugular cordis was inserted under local anesthesia. Gentle anesthetic in- duction was achieved with intravenous propofol, fentanyl and rocuronium. Tracheal intubation was uneventful with tight control of systolic blood pressure, as there was a high risk of rupture due to size. Baseline echocardiography exam was obtained via TEE. Estimated EF was 50% - 55%. ACT's were monitored throughout the procedure. Open surgical repair was carried out with a midline incision in three stages using a Hemashield bifurcated il- iac graft. The third and fourth portions of the duodenum were contiguous with the aneurysm. Firstly, after systemic heparinization the external iliac arteries were clamped fol- lowed by infra-renal aortic clamping, dissection and evac- uation of thrombus with end-to-end anastomosis of the graft to the infra-renal aorta. A clamp was applied to the graft itself followed by slow release of aortic clamp to ver- ify suture line haemostasis. The second and third stages of repair involved clamping the internal iliac arteries, dissec- tion and end-to-end anastomosis the graft to distal com- mon iliac arteries. Fluid was restricted prior to cross clamping. As in- traoperative hypotension has been associated with post-