Leaking Abdominal Aortic Aneurysm Research Articles

Mycotic aortic aneurysm in a debilitated patient with compromised immunity; beware of Candida!

Candida is a rare cause of infected aortic aneurysms. We report the case of a diabetic patient with end stage kidney disease who underwent repair of a leaking abdominal aortic aneurysm. He was on long-term antibiotic treatment for malignant otitis externa. Candida albicans was isolated from the culture of the excised aneurysm wall. An infected aortic aneurysm due to Candida has not been previously reported in a patient with malignant otitis externa. This case report aims to highlight that Candida should be suspected as a cause of infected aortic aneurysms in patients with debilitation and chronic immunosuppression. Management of such cases can be extremely challenging, especially in resource-poor settings, and we will be touching upon the advantages and disadvantages of various treatment options.

An Abdominal Aortic Aneurysm, Intramural Thrombus and Moderate Leak in an Asian Man Presenting with Acute Gastroenteritis.

IntroductionMissing a leaking abdominal aortic aneurysm (AAA) is common in medical practice because few at-risk patients have a history of AAA and many have an unusual presentation.BackgroundAAA is less common among Asians than white Caucasians of the same age. Our patient had no significant risk factors apart from age and sex and had an unusual presentation.Patient and MethodsA 67-year-old Asian man presented to the emergency room (ER) with a 1-day history of nausea, vomiting, diarrhoea, fever and abdominal pain. He was febrile, dehydrated. and had marked tenderness at the right iliac fossa. Laboratory findings suggested bacterial gastroenteritis but this did not explain the localized tenderness at the right iliac fossa.Result and DiscussionA CT scan of the abdomen revealed an AAA arising above the origins of the renal arteries, an intramural thrombus, a retroperitoneal haematoma and a leak extending to the right iliac fossa. The patient was transferred to another hospital and underwent exploratory laparotomy, surgical repair of the aneurysm, and aortobi-iliac grafting with removal of the thrombus. The patient was discharged in good shape 3 weeks after surgery. Without the CT scan of the abdomen, the AAA could have been missed and the patient treated for severe gastroenteritis.LEARNING POINTSAlthough abdominal aortic aneurysm leak is a rare differential diagnosis for elderly Asian patients with abdominal pain, it should be still suspected and investigated accordingly.In our elderly patient, as localized tenderness on clinical examination could not be explained by the gastroenteritis, an imaging study was essential to rule out a surgical cause.

Inflammatory mantle completely surrounding a leaking abdominal aortic aneurysm

Inflammatory mantle completely surrounding a leaking abdominal aortic aneurysm

Inferior Vena Cava Stent-Graft Placement to Treat Endoleak Associated With an Aortocaval Fistula

To report a case in which a persistent high-flow type II endoleak after endovascular aneurysm repair (EVAR) of a leaking abdominal aortic aneurysm (AAA) complicated by an aortocaval fistula was repaired with a stent-graft in the inferior vena cava (IVC). A 76-year-old man underwent emergent EVAR with an aortomonoiliac device to exclude a leaking 9-cm AAA. The 30-day computed tomography (CT) scan showed 2-mm sac expansion and a type II endoleak arising from a lumbar artery; the outflow vessel was the inferior vena cava (IVC) via a fistula that was not depicted on the non-contrast preoperative CT or the intraoperative angiogram. No intervention was deemed necessary at the time. Six months after EVAR, the AAA had not expanded further, but the fistula between the sac and the IVC was larger in diameter. A tubular stent-graft was implanted in the IVC to seal the defect. No complications have been noted up to 36 months after the IVC stent-graft procedure. Aortocaval fistulae should be excluded in the case of persistent type II endoleaks after EVAR for ruptured AAAs. IVC endografting is a minimally invasive alternative to treat such a complication, with promising midterm results in this patient.

Emergency Medicine Ultrasound Simulation (US/S) Case Scenario Package

OPEN ACCESSApril 5, 2010Emergency Medicine Ultrasound Simulation (US/S) Case Scenario Package Leo Kobayashi, MD, Marc Shapiro, MD, Arun Nagdev, MD, Frantz Gibbs, MD Leo Kobayashi, MD The Warren Alpert Medical School of Brown University Google Scholar More articles by this author , Marc Shapiro, MD The Warren Alpert Medical School of Brown University Google Scholar More articles by this author , Arun Nagdev, MD The Warren Alpert Medical School of Brown University Google Scholar More articles by this author , Frantz Gibbs, MD The Warren Alpert Medical School of Brown University Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.531 SectionsAboutAbstract ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstractThis resource consists of a modular package containing five high-fidelity full-body simulation case scenarios with supplemental bedside emergency department ultrasound videos (deidentified) to assist in emergency medicine decision-making training. Developed for our emergency medicine residency curriculum, this ultrasound simulation program supplements established educational interventions in which residents learn basic emergency ultrasound principles and are mentored individually in standard image-acquisition techniques on consenting patients. Emergency ultrasound and medical simulation faculty collaborated on a program to help trainees apply bedside sonography in real time to critical patient care decisions inside a risk-free learning environment. To generate simulated images necessary for emergency ultrasound application training, we compiled a PC-based sonographic image library of deidentified normal and pathologic findings. To minimize cost, a donated laptop was loaded with imaging software and the sonographic library, attached to a nonfunctioning ultrasound probe, and placed on an IKEA cart approximating commercially available emergency ultrasound stands. The five cases feature high-acuity simulation scenarios with occult but profound pathology requiring rapid decision making based on appropriate emergency ultrasound utilization: (1) right ventricular strain accompanying pulseless electrical activity from massive pulmonary embolism, (2) pericardial tamponade in a hypotensive uremic patient, (3) serial FAST (focused abdominal sonography in trauma) exams with interim development of detectable hemoperitoneum in a trauma patient, (4) Morrison's pouch fluid in a hypotensive female with ruptured ectopic pregnancy, and (5) leaking abdominal aortic aneurysm in an elderly patient with back pain. The inclusion of sonographic movie files in the clinical scenarios adds significantly to simulation verisimilitude for participants. This course has been incorporated in the Warren Alpert Medical School's emergency medicine residency education program at Brown University. Educational Objectives By the end of this resource, learners will be able to: Integrate simulated ultrasonographic findings with manikin-based simulation scenarios to apply bedside sonography in real time to critical patient care decisions.Understand the features of five high-acuity trauma and medical patients.Assist in education of diagnosis and management of massive pulmonary embolism, pericardial tamponade/cardiogenic shock, multitrauma, ectopic pregnancy, and abdominal aortic aneurysm. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Society for Academic Emergency Medicine.doc World Congress Ultrasound 2006.doc USS Session Image1 RIHMSC.jpg USS Session Image2 RIHMSC.jpg Sim Ultrasound Cart RIHMSC.jpg USS Laerdal SimMan Programming USS Case 1 USS Case 2 USS Case 3 USS Case 4 USS Case 5 To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2010 Kobayashi et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsEctopic PregnancyPulmonary EmbolismPericardial EffusionAbdominal Aortic AneurismMulti-Trauma Disclosures None to report. Funding/Support None to report. Loading ...

Supraventricular Tachycardia in a Patient With a Ruptured Abdominal Aortic Aneurysm: Conclusion

A transport request was received from a free-standing emergency facility to transport a morbidly obese man with a ruptured abdominal aortic aneurysm (AAA). Weather conditions at the time prohibited rotor-wing transfer, so ground transport was arranged. The patient was a 58-year-old man being worked up for a possible back injury. During the evaluation, the patient had an episode of supraventricular tachycardia (SVT) with associated hemodynamic instability. Although the SVT corrected without intervention, the patient remained hemodynamically unstable. An abdominal computed tomographic (CT) scan with intravenous (IV) contrast demonstrated a 10-cm leaking abdominal aortic aneurysm. The patient complained of severe heartburn and abdominal pain. He had a significant medical history, including a previous three-vessel coronary artery bypass graft surgery, non-insulin-dependent diabetes, and chronic renal insufficiency. Physical examination was significant for limited mouth opening, limited neck mobility, a previous median sternotomy scar on the chest, and a markedly distended abdomen. Vital signs demonstrated a heart rate of 138 beats/min, respiratory rate 28 breaths/min, blood pressure 103/47 mmHg, and an oxygen saturation of 93% on 15 L/min by a nonrebreather (NRB) mask. Sinus tachycardia was identified on the monitor. Vascular access included an 18-gauge IV line in the right hand, a 16-gauge IV line in the left antecubital fossa, and a 7.5-French triple-lumen catheter in the right subclavian vein. Dopamine was running at 10 mug/kg/min. A unit of packed red blood cells (PRBCs) was also noted to be infusing at a rate of 999 mL/hour by infusion pump. Blood transfusion continued, and the dopamine was decreased to 5 mug/kg/min and eventually able to be discontinued. Despite this, approximately 15 minutes into the transport, the patient had another episode of SVT.

Lethal cause of abdominal pain: a diagnosis not to be missed

A 77-year-old woman was brought to the accident and emergency department with a 11-day history of abdominal pain. She was in shock and required resuscitation. She had attended the accident and emergency a few days before and had been discharged home with a diagnosis of non-specific abdominal pain. The previous abdominal X-ray is shown in Figure 1. Her past medical history included bilateral below knee amputation for peripheral vascular disease, pacemaker for heart block and hypertension. On examination, post-resuscitation, she was confused and apyrexial with a heart rate of 100 beats/minute and a blood pressure of 110/70 mmHg. Her abdomen was diffusely distended with minimal tenderness in the epigastrium and supra-umbilical region. There was no rigidity or guarding. Bowel sounds were normal. Digital rectal examination showed soft faeces. Blood test showed a haemoglobin of 6.6 g/dl (down from 11 g/dl during her previous accident and emergency visit). There was slight impairment of renal function with a urea of 11 mg/dl and creatinine of 160 mg/dl. The rest of the blood tests were within normal limits. Arterial blood gases showed metabolic acidosis with a pH of 7.2 and lactate of 3 mmol/litre. A computed tomography scan of the abdomen was performed. 1. What is the differential diagnosis? 2. What can you find in the abdominal X-ray? 3. What can you find in the computed tomography scan? 4. What is the treatment? 5. What is the prognosis of this patient? The differential diagnoses in this case are peritonitis from hollow viscus perforation, ischaemic bowel and leaking abdominal aortic aneurysm. The abdominal X-ray (Figure 1) shows minimal dilatation of the right and transverse colon and a tortuous calcified aorta. However the upper aortic calcification is not obvious. Computed tomography scan shows an abdominal aortic aneurysm which commences immediately distal to the origin of the right renal artery with not involving the bifurcation. There is leakage from this aneurysm (Figure 2b arrow) which has a maximum diameter of 5 cm. There is a periaortic haematoma which extends anteriorly to displace the loops of bowel anteriorly (Figure 2b). There is free fluid in the peritoneal cavity (Figure 2a). The right kidney is well perfused but the left kidney shows no evidence of perfusion (Figure 2c). There are some calculi in the left pelvis. In this patient, palliation was felt to be the most appropriate treatment option (her case was discussed with the on-call vascular surgeons). The patient died a few hours after her hospital admission. In a relatively fitter patient, open surgery is the treatment of choice.

Systemic Administration of Heparin Intraoperatively in Patients Undergoing Open Repair of Leaking Abdominal Aortic Aneurysm May Be Beneficial and Does Not Cause Problems

The aim of this study was to investigate whether intravenous heparin administration was associated with a reduction in perioperative mortality and late distal thrombectomy in patients with ruptured abdominal aortic aneurysms (AAAs). One hundred thirty-one patients had repair of ruptured AAA between January 1999 and January 2004. Sixty-three received heparin according to the consultant's preference at the time of the operation. Data were prospectively collected, and multivariate analysis was performed for independent predictive factors. Thirty-day mortality was 29%. Patients receiving heparin had lower perioperative mortality (16% vs 42%; p= .001). Heparin administration was not associated with increased hemorrhage or transfusion. Multivariate analysis confirmed that heparin administration was independently predictive of survival (p= .036). Other factors found to reduce survival were age (p= .023), smoking (p= .042), and systolic blood pressure (<100 mmHg) at presentation (p= .045). Fewer patients had thrombectomy after heparin (8% vs 12%), but this was not statistically significant. Perioperative complications were similar in both groups. The administration of systemic heparin before the clamp is applied to leaking aneurysms does not appear to increase hemorrhage and subsequent mortality and may reduce the need for early thrombectomy.

Intraoperative autotransfusion for elective aortic surgery.

Intraoperative autotransfusion using the Bentley ATS 100 was used in 23 patients requiring Dacron replacement of their abdominal aorta. An average 2000 ml of blood was reinfused and a total heparinization dose was given. The mean haemoglobin fell 2.8 g/dl and on average 2 pints of banked blood were given in the postoperative period. Coagulation studies performed before and after surgery showed minimal alteration. We feel that further evaluation of this system is essential so that an alternative is established for when banked blood is not available. The system is particularly useful at the present time for such emergencies as a leaking abdominal aortic aneurysm and severe trauma to the liver.

Ruptured abdominal aortic aneurysm complicated by horseshoe kidney and renal cell carcinoma

A74-year-old man presented emergently with acute left flank pain. Examination revealed a tender, distended abdomen. A single image from the enhanced abdominal computed tomography scan revealed a leaking abdominal aortic aneurysm (AAA) and horseshoe kidney (HK), with a 3.5-cm solid mass in the left lower pole (Fig. 1). The patient became hypotensive and was immediately taken to the operating room.

Delayed Presentation of Rectal Ischaemia Following Aortic Surgery: Rectal Stricture, Local Perforation and Graft Infection

We report a case of ischa-emic rectal stricture following emergency repair ofa leaking abdominal aortic aneurysm, complicatedby a delayed local perforation, and secondary graftinfection.Case HistoryA 71-year-old male underwent emergency aortobi-femoral repair for a leaking abdominal aortic aneur-ysm with iliac aneurysmal dilatation. He sustained aprolonged period of hypotension during the proced-ure, and the patent inferior mesenteric artery wasligated. The common iliac arteries were oversewn attheir origin.His recovery was complicated by a prolonged per-iod of ventilation, wound haematoma in the left groin(which was managed conservatively) and post-operative diarrhoea without bleeding. Symptoms ofintractable diarrhoea persisted after discharge for sev-eral weeks. Multiple stool samples failed to identifyany pathogenic organism and Clostridium difficiletoxin could not be identified in the bloodstream.Rigid sigmoidoscopy revealed a smooth upper rectalstricture, though the rectal mucosa appeared normal;biopsies revealed patchy acute inflammatory cell infil-trate in the lamina propria. A gastrograffin enema(Fig. 1) confirmed this, and identified a very smallleak of contrast into the pararectal tissues, as well assigmoid diverticular disease. Dilatation of the stricturewas planned.Before this could be done he presented acutely tocasualty with a painful swelling in the left iliac fossaand groin. He gave a two months history of nightsweats, progressive anorexia, malaise, lethargy, andchronic diarrhoea. He was pyrexial and there was atender, erythematous, non-pulsatile 8cm diameterswelling in the left iliac fossa above the scar from theprevious groin incision. Digital rectal examination wasnormal. An urgent CT scan of the aorta confirmed thediagnosis of graft infection, with a gas/fluid filledcollection visible around the left limb of the graft(Fig. 2).At laparotomy the trunk and right limb of the graftwere well incorporated; the left limb of the graft waspoorly incorporated and surrounded by pus. It wasexcised and a left axillo-popliteal bypass constructedwith a silver-coated graft. The remainder of the lapar-otomy appeared normal, and there was no evidenceof colonic perforation. However seven days post-operatively faeces discharged from the left groinwound. The patient underwent emergency re-laparot-omy; a perforation of the upper rectum was nowobvious, and a Hartmann’s procedure performed.Examination of the specimen revealed a smoothbenign stricture of the upper rectum with a localperforation.

Left lower quadrant pain of unusual cause

The differential diagnosis of left lower quadrant abdominal pain in an adult man includes, among others, sigmoid diverticulitis; leaking abdominal aortic aneurysm; renal colic; epididymitis; incarcerated hernia; bowel obstruction; regional enteritis; psoas abscess; and in this rare instance, situs inversus with acute appendicitis. We report a case of situs inversus totalis with left-sided appendicitis and a brief review of the literature. There were several subtle indicators of total situs inversus present that were missed by the physicians and surgeons who initially evaluated the patient prior to surgery. Computed tomography scan with contrast, however, revealed the diagnosis immediately, and treatment was successfully initiated.

Survival After Failed Intraoperative Resuscitation: A Case of “Lazarus Syndrome”

Survival After Failed Intraoperative Resuscitation: A Case of “Lazarus Syndrome”

Ruptured Abdominal Aortic Aneurysm and Inferior Vena Cava Occlusion in Behqet's Disease

Behqet's disease is a rare, multisystem disorder characterized by widespread vasculitis on both the arterial and venous side of the circulation. The authors report a very rare case of associated leaking abdominal aortic aneurysm and Budd-Chiari syndrome secondary to inferior vena cava occlusion in a 25-year-old woman with complicated Behqet's disease. To our knowledge, this is the fourth case to be reported in the English literature with such a combination.

Aortoduodenal and Aortocaval Fistula with an Accessory Left Renal Artery Aneurysm Presenting with Heart Failure and Chronic Anemia Due to Hematemesis

The authors present what they think to be the first successfully managed case of a leaking abdominal aortic aneurysm associated with an aortocaval and aortoenteric fistula and an accessory left renal aneurysm reported in the English literature.

Perioperative care of a Jehovah's Witness with a leaking abdominal aortic aneurysm

We describe a Jehovah's Witness patient who survived emergency repair of a leaking abdominal aortic aneurysm. In accordance with his beliefs, the patient expressed a wish not to be given blood and this was respected. At completion of surgery, his haemoglobin was 2.8 g dl-1 and his albumin was 8 g l-1. He was kept heavily sedated in the intensive care unit and treated with i.v. iron, folinic acid and s.c. epoetin alfa. He was discharged to the high dependency unit 18 days after surgery with a haemoglobin of 6.4 g dl-1 and an albumin of 27 g l-1. After rehabilitation, he was discharged home approximately 14 weeks after surgery.

Massive blood transfusion in a tertiary referral hospital

To determine blood products used, clinical outcomes and frequency of haemostatic complications of massive blood transfusion. Retrospective review of the medical records of patients receiving more than 10 units of blood in 24 hours at a tertiary referral hospital in 1993. Forty-three patients fulfilled this criterion. The major reasons for massive transfusion were trauma (46%; 20 patients), gastrointestinal bleeding (21%; nine patients) and leaking abdominal aortic aneurysm (14%; six patients). Blood products used, platelet count ( < 50 x 10(9)/L in first 48 h), prothrombin time (PT) and activated partial thromboplastin time (APTT) (twice normal in first 48 h), microvascular bleeding, and survival. The 43 patients used 824 units of packed cells 15.2% of the total used in 1993), 457 units of fresh frozen plasma (FFP) (17.1% of the 1993 total) and 370 units of platelets (14.8% of the 1993 total). Overall, these patients consumed 16% of the total number of units of blood product used in 1993 for 1478 transfusion episodes. The overall survival rate was 60%. Severe coagulopathy occurred in 19 patients (44%) (mortality rate, 74%), and 13 (31%) had severe thrombocytopenia ( < 50 x 10(9)/L). There was no significant correlation between the severity of coagulopathy/thrombocytopenia and total units transfused, or between the age of the units of blood and development of coagulopathy or microvascular bleeding. Severe coagulopathy is common after massive transfusions. In the absence of clear correlation with the number of units transfused, "formula" replacement with plasma and platelets is unlikely to avoid the problem. Duration of tissue hypoperfusion and platelet consumption are likely to be more important than simple haemodilution of coagulation factors.

Aortic Aneurysm Rupture Into a Retroaortic Left Renal Vein

We report the case of a patient who was transferred to our facility after a CT scan obtained at a local hospital revealed a leaking abdominal aortic aneurysm. Review of the scan showed an aorto-left renal vein fistula. Knowing this fistula was present made the operative repair of the aneurysm and control of the fistula much more straightforward than might otherwise have been the case. Although relatively rare, major anomalies of the renal veins and perirenal vena cava should be borne in mind when operating on the abdominal aorta. This case illustrates the merit of contrast-enhanced CT scanning prior to aortic surgery.

Leaking abdominal aortic aneurysm presenting as an inguinal mass

Two patients with leaking abdominal aortic aneurysm (AAA) presenting as a tender inguinal mass are reported. Unusual presentations such as this often cause delays in definitive surgery which result in increased morbidity and mortality. It follows that the diagnosis of a leaking AAA should be considered in all patients with a tender pulsatile abdominal mass regardless of the presentation.

Ruptured Common Iliac Artery Aneurysm Presenting with Perianal Hematoma—A Case Report

A case of ruptured common iliac artery aneurysm is reported. The patient presented with a perianal hematoma and had undergone repair of a leaking abdominal aortic aneurysm seven years previously. The presentation and man agement are discussed.