Successful surgical reconstruction of a giant ruptured abdominal aortic aneurysm. A case report

Anatomical repair of a congenital aneurysm of the distal abdominal aorta in a newborn

IntroductionIt is rare for two critical diseases, namely a giant abdominal aortic aneurysm (AAA) and acute type A aortic dissection (TAAD), to be detected simultaneously, and in such instances, management is extremely difficult. Presentation of caseA 64-year-old man who presented to our hospital with a chief complaint of sudden back pain and vomiting was diagnosed with acute retrograde TAAD and a giant AAA with chronic contained rupture (CCR) via computed tomography. We initially managed the acute TAAD conservatively and subsequently performed laparotomy for the AAA 3 months later. During open surgery, we performed vascular reconstruction using a tailor-made tapering graft. DiscussionEmergency surgery is recommended for AAA with CCR or retrograde TAAD with a patent false lumen, and the prognosis of conservative treatments for these cases is currently unknown. However, concurrent surgery for this condition is extremely invasive. Fortunately, the patient in this case survived the acute phase, and laparotomy for the AAA could be safely performed during the chronic phase of the TAAD. ConclusionWe successfully treated a giant AAA with CCR by selecting the appropriate surgical timing and method. In cases of combined CCR of a giant AAA and retrograde TAAD, conservative management may be attempted to convert the acute dissection to a chronic one, thereby allowing elective repair of the AAA.

An abdominal aortic aneurysm is considered giant when its transverse diameter is greater than 10-13cm in diameter. A giant abdominal aortic aneurysm is rare but with a significant risk of rupture if it is not diagnosed or left untreated. The authors have performed a systematic review of the evidence that has looked into the clinical presentations, and management methods employed and have presented a 14cm giant abdominal aortic aneurysm patient. The systematic review has been based on level-IV evidence due to the rarity of the condition. The final analysis included 61 relevant reported cases. The mean age was 72.4years, the male to female ratio was 52: 8, and the average size of a giant abdominal aortic aneurysm was 14.7cm. These were mostly infra renal (72.58%). Rupture of these aneurysms was found in 23 (37.1%) patients, and was treated by laparotomy in 51 (82.25%) cases. There were 11 (17.74%) mortalities. The size of an abdominal aortic aneurysm is known to be the biggest factor in the rupture of an aneurysm. The reason abdominal aortic aneurysms can reach such size without rupturing is unclear but needs further exploring. Early diagnosis with effective screening programmes is essential to diagnose in a timely manner to avoid life-threatening consequences.

Primary aortoenteric fistula following endovascular aortic repair due to type II endoleak

Rationale:Abdominal aortic aneurysm is one of the most common aneurisms. Patients presenting with secondary back pain should be given prompt medical attention. Herein, a rare case of a giant abdominal aortic aneurysm that was successfully treated with surgery is described.Patient concerns:A 33-year-old Chinese male suffered from Marfan syndrome combined with giant abdominal aortic aneurysm, and presented with back pain, fever, nausea, vomiting, abdominal distention, and constipation. After undergoing numerous tests, the patient underwent an abdominal aortic aneurysm resection coupled with artificial graft bypass. The patient's recovery was smooth, and he was discharged 14 days after the operation in stable condition.Diagnosis:Abdominal aortic aneurysm.Interventions:The patient underwent a surgery involving mass resection and artificial graft bypass.Outcome:The patient was discharged 14 days after surgery in stable condition.Lessons:Giant abdominal aortic aneurysms are rarely seen, and aneurysmectomy associated with prosthetic vascular graft repair is an effective and standard treatment for such aneurysms.

Article1 June 1956THE CLINICAL PICTURE OF ANEURYSM OF THE ABDOMINAL AORTACHARLES D. ENSELBERG, M.D., F.A.C.P.CHARLES D. ENSELBERG, M.D., F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-44-6-1163 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptAlthough aneurysms (chiefly traumatic) were known to Galen, discussions of this subject in the medical literature began to increase in the 16th Century along with the increasing appearance of syphilis. Abdominal aneurysms were described by Fernelius in 1542 and by Vesalius in 1595.2, 3Lancisi4in 1728 observed the relationship between syphilis and aneurysm, and published clinical and pathologic descriptions of ruptured abdominal aortic aneurysm. Monro,5describing a case he saw in 1760, wrote: "At that time he was troubled with a hiccup, which had begun the day before I saw him. The pain of his belly was almost constant,...Bibliography1. Klotz O: Concerning aneurysms, U. of Toronto Studies, Path. Series, No. 7, 1926. Google Scholar2. Erichsen JE: Observations on aneurism, 1844, The Sydenham Society, London. Google Scholar3. Osler W: Aneurysm of the abdominal aorta, Lancet 2: 1089, 1905. CrossrefGoogle Scholar4. Lancisi GM: De Aneurysmatibus, Rome, 1745, revised and translated by W. C. Wright, 1952, Macmillan Co., New York. Google Scholar5. Monro D: Cases of aneurisms, with remarks. Essays and observations, physical and literary, Edinburgh 1771. Google Scholar6. Nixon JA: Abdominal aneurysm in a girl aged twenty due to congenital syphilis, with tables of collected cases of abdominal aneurysm, St. Barth. Hosp. Rep. 17: 43, 1912. Google Scholar7. LuckeRea BMH: Studies on aneurysm. I. General statistical data on aneurysms, J. A. M. A. 77: 935, 1921. CrossrefGoogle Scholar8. Kampmeier RH: Aneurysm of the abdominal aorta: a study of 73 cases, Am. J. M. 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SchlossKaplan WABJ: Spontaneous extravasation from the ureter secondary to aneurysm of the abdominal aorta, New England J. Med. 249: 802, 1953. CrossrefMedlineGoogle Scholar44. Petersen GF: Atherosclerosis of the abdominal aorta, Acta radiol. 37: 356, 1952. CrossrefMedlineGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: New York, N. Y.*Read at the Twenty-eighth Scientific Session, American Heart Association, New Orleans, October 24, 1955. Received for publication January 17, 1956.From the Department of Cardiology, New York Polyclinic Medical School and Hospital, and the Medical Division, Montefiore Hospital, New York, N. Y. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byAn Unusual Case of Testicular PainReferred scrotal painThe blue scrotum sign of Bryant: A diagnostic clue to ruptured abdominal aortic aneurysmRuptured abdominal aortic aneurysm causing obstructive jaundiceAneurysmen 1 June 1956Volume 44, Issue 6Page: 1163-1181KeywordsAbdominal aortic aneurysmAbdominal painAneurysmsAortaHeartHemorrhageHipReflexesSyphilisUreter ePublished: 1 December 2008 Issue Published: 1 June 1956 PDF downloadLoading ...

Abdominal aortic aneurysms are the most common types of aneurysms worldwide, whereas aneurysms in the blood vessels of the abdominal organs (splanchnic aneurysms) are rare. Few studies have reported cases of two giant aneurysms occurring simultaneously. Presented here is a case of a 67-year-old man who began to experience periumbilical pain with a diagnosis of a giant abdominal aortic aneurysm and a hepatic artery aneurysm. He was successfully treated using a staged endovascular stent grafting procedure. Postoperatively, the patient's abdominal pain was resolved, and he was prescribed medication for hypertension control, lipid control, heart rate control, antiplatelet therapy, and smoking cessation, which he took regularly. Follow-up evaluations were performed at 3, 6, and 9 months after surgery, and no late complications were observed. This case report suggests that when two giant aneurysms are diagnosed simultaneously, risk of rupture, surgical interventions, and postoperative complications are significantly increased. The choice of a treatment strategy is complex and has a high degree of individual specificity.

Abdominal aortic aneurysm (AAA) causes 170,000 deaths worldwide. In the Philippines, 100,000 estimated number of Filipinos have aortic aneurysm at any given time. AAA is defined as dilatation of a wall of more than 3 cm in diameter at any segment or a diameter greater than or equal to 1.5x of the aortic diameter at the level of the diaphragm. Giant abdominal aneurysm is defined as aneurysm with a diameter of more than 10 to 13 cm in the maximum transverse diameter. Several risk factors were identified such as hypercholesterolemia, advanced age, male sex, hypertension, smoking, family history and connective tissue disease. The prevalence of rupture annually of giant abdominal aneurysm was 30%-50% and this required surgical repair. We report the case of a 60-year-old Filipino male, a known hypertensive and chronic smoker with no family history of aneurysm and connective tissue disease who presented with a visible pulsatile mass on the hypogastric region and associated with left lower quadrant pain radiating into the back. Upon admission a CT aortogram was done and revealed giant infrarenal fusiform aneurysm measuring 11.6 cm x 9.4 cm x 16.9 cm (T x AP x L) with dilatation of the proximal bilateral common iliac arteries, each measuring 2.6 cm in diameter. Open surgical approach was the best option of treatment over endovascular repair (EVAR) to the patient due to unfavorable neck anatomy of the infrarenal aneurysm that may greatly affect device delivery. The patient underwent exploratory laparotomy with endoaneurysmorrhaphy and bifurcated graft aortoiliac anastomosis with intraoperative findings of 12 cm in transverse diameter of fusiform infrarenal aneurysm extending to bilateral common iliac arteries. The patient improved and was discharged after 10 days. We highlight the significance of giant aneurysms with prevalence of 0.03%. It is still unknown the exact mechanism of giant abdominal aneurysm which have reached this size and remain unruptured. Keywords: Abdominal aortic aneurysm; giant abdominal aortic aneurysm; endoaneurysmorrhaphy; endovascular repair of abdominal aortic aneurysm (EVAR)

A 76-year-old male with a medical history of smoking and hypertension was admitted to our clinic with a ruptured abdominal aortic aneurysm (AAA) diagnosed by a trans-abdominal ultrasound. He was immediately brought to the emergency room (ER). His blood pressure was 80/40 mm Hg, with an HTC of less than 0.17. Six years earlier, he had noticed a painless, enlarging abdominal mass. An emergency abdominal computed tomographic angiography (CTA) with intravenous contrast showed a giant infrarenal AAA measuring 13x11 cm in diameter, with clear evidence of rupture and a large intra-abdominal hematoma (Figure 1). He was immediately brought to the operating theater (OT). Figure 1 Abdominal computed tomographic angiography with contrast showing: A) a ruptured giant abdominal aortic aneurysm (AAA), measuring 13x11 cm with B) a large inta-abdominal hematoma, that compresses the intra-abdominal organs. C) and D) showing a ruptured ... The approach to the abdomen was a classic median laparotomy. After we had opened the abdomen, we found a huge retroperitoneal hematoma that pushed beside the intra-abdominal organs rising almost to the edge of the rectal fascia. His blood pressure suddenly dropped to 45/25 mm Hg for the next several minutes. A continuous infusion of norepinephrine was administered (60 mcg/min), several doses of pure adrenalin (3 mg) and pure norepinephrine (1 mg). His blood pressure immediately rose to 80 mm Hg. During the surgery he was anuric. Autologous blood transfusion helped by cell saver was administered. Additionally, he received several doses of blood, blood derivates (fresh frozen plasma, cryoprecipitate, platelets), and other intravenous solutions totaling approximately 8 liters. We replaced the ruptured AAA using a 20 mm polytetrafluoroethylene (PTFE) vascular graft. After surgery he was transferred to the intensive care unit (ICU) where the blood pressure rose, and diuresis was established (Figure 2). Figure 2 Postoperative computed tomographic angiography (CTA) with contrast showing: A) complete sealing of the aneurysm and no endoleak detected. B) Abdominal CTA with contrast showing patency of the graft. On the first postoperative day, he was woken up without neurological deficits. Six days after surgery we performed a control CT angiography that showed normal findings on the abdominal iliac and leg vessels. Recovery was uneventful and he was discharged from hospital on postoperative day 10. Aneurysm size is the most important factor related to likelihood of rupture, and the risk increases substantially in large aneurysms. The annual rupture risk for AAA’s >8 cm is 30-50%.1 Symptomatic aneurysms present with back, abdominal, buttock, groin, testicular, or leg pain and require urgent surgical attention. Rupture of an AAA involves complete loss of aortic wall integrity, and is a surgical emergency requiring immediate repair.2 The sheer size of the aneurysm, the short length of the neck, and the dislodgment of abdominal organs that may be densely adhered to its surface with fistula formation, make surgery of this entity very challenging. Open repair of giant AAA’s is often the only available treatment, though not always with good results.3 In conclusion, open surgical repair is often the only viable treatment because aneurysm size implicates an adverse neck anatomy that makes these AAA’s not suitable for endovascular aneurysm repair.4 The repair of these giant aneurysms presents a challenge during surgery. Ruptured giant AAA’s present a significant additional surgical and anaesthetic challenge.

IntroductionCoronary artery disease (CAD) is commonly associated with abdominal aortic aneurysms (AAAs) in elderly patients. When severe CAD requiring coronary artery bypass grafting (CABG) is associated with an impending AAA in a high-risk patient, the options for the suitable timing of CABG and AAA repair strategy (one-stage or two-stage) are still being debated. Presentation of caseAn 87-year-old man with non-ST-segment elevation myocardial infarction and a giant abdominal aortic aneurysm was transferred to our centre. Coronary angiography revealed triple-vessel coronary disease, and computed tomography confirmed a giant infrarenal fusiform abdominal aortic aneurysm 9 cm in maximal diameter. We simultaneously performed endovascular aneurysm repair prior to on-pump beating-heart coronary artery bypass grafting. The postoperative course was uneventful, and the patient was discharged on the 15th postoperative day. ConclusionCombined endovascular aneurysm repair and on-pump beating heart coronary artery bypass grafting in a one-stage operation is a promising strategy to improve therapeutic efficiency in octogenarians. More studies are needed to compare the efficacy and safety of one-stage and two-stage operations to treat concomitant coronary artery disease and aortovascular pathology in the high-risk octogenarian patients.

A horseshoe kidney is one of the most common anomalies of renal structure. This pathology combined with an abdominal aortic aneurysm is of special interest because surgical policy for the patient cohort concerned is not standardized and depends on a plurality of individual anatomical peculiarities. Described herein is a clinical case report regarding successful surgical treatment of a patient presenting with a giant abdominal aortic aneurysm and a coexisting horseshoe kidney. Through a laparotomic access, we performed resection of the juxtarenal abdominal aortic aneurysm, aortic-common-iliac bifurcation prosthetic repair using a synthetic bifurcated graft with reimplantation of the right renal artery into the aorta. At the stage of aneurysm resection, perfusion of the kidney with autologous blood was performed through the right renal artery. The postoperative period proved uneventful. The levels of blood urea and creatinine did not exceed the admissible values. The patient was discharged home on POD 10 in a satisfactory condition.

The modern open surgical management of abdominal aortic aneurysm (AAA) has changed little since its inception in the 1950s. Endoaneurysmorrhaphy, first described by Rudolph Matas in 1888, involved ligating the branches of an aneurysm from within the aneurysm sac. Approximately 25 years later at the

Infected splenic artery aneurysm with associated splenic abscess formation secondary to bacterial endocarditis: Case report and review of the literature

Exercise, Vascular Health, and Abdominal Aortic Aneurysms

Today, abdominal aortic aneurysm surgery is a fairly well-studied area of medicine. Nevertheless, some questions remain rather debatable. No clear criteria for giant aneurysms have been developed so far. The available foreign and domestic literature reports about 40 cases of surgical treatment of giant abdominal aortic aneurysms, 16 of which are cases of aneurysm rupture. Open surgery remains the method of choice in the treatment of giant aneurysms due to the pronounced technical difficulties of endovascular intervention. The authors present a case of successful surgical treatment of a giant aneurysm rupture in an elderly patient. The peculiarity of this patient's condition is the occurrence of aneurysm rupture after hospital admission. The patient refused surgical treatment for two years after aneurysm detection. On examination after admission, multispiral computed tomography revealed an aneurysm size of 101 mm. On the eve of surgery, pain syndrome in the left abdomen and tachycardia appeared. Aneurysm rupture was suspected and the patient was urgently admitted to the operating room. The surgery was performed under the conditions of machine reinfusion of autoblood. The patient underwent abdominal aortic aneurysm resection with linear prosthesis and retroperitoneal hematoma removal. The postoperative period had no peculiarities. On the 10th day after the operation the patient was discharged in satisfactory condition to the outpatient treatment. This clinical case demonstrates the possibility of successful surgical treatment of giant aneurysm rupture in elderly patients.