Symptomatic
large abdominal aortic aneurysm in a patient with thoracoabdominal aortic
dissection sequelae
(Portuguese
PDF version)
Coordinated
by Fausto Miranda Jr.
Telmo P Bonamigo1, Lenine Cunha2,
Nilton Brandão da Silva3
1.
Head of the Division of Vascular Surgery, Irmandade da Santa Casa
de Porto Alegre. Associate Professor of Vascular Surgery, Fundação
Faculdade de Ciências Médicas de Porto Alegre.
2. Head of the Service of Computed Tomography, Hospital São
Francisco, Santa Casa de Misericórdia, Porto Alegre.
3. Associate Professor, Fundação Faculdade de
Ciências Médicas de Porto Alegre.
Correspondence:
Dr. Telmo P. Bonamigo
Rua Coronel Bordini, 675/303
CEP 90440-001 - Porto Alegre - RS
Brasil
Tel./Fax: (51) 3333.1642
E-mail: telmobonamigo@terra.com.br
J Vasc
Br 2003;2(3):233-34
Sixty-four-year-old
male patient with previous history of systemic arterial hypertension
for over 20 years, treated in 1993.
The patient had been admitted to the Hospital de Cardiologia eight years
ago (1985) when he presented with typical symptoms of acute aortic dissection
(AAD) type B, and received clinical treatment, with good immediate results.
After that, the patient began to control the risk factors and took his
antihypertensive medication rigorously. He has carried out his working
activities normally throughout eight years.
Three months ago, the patient complained of low abdominal pain, which
was less intense at the beginning and gradually increased, followed
by the formation of a pulsatile abdominal mass. The patient was kept
on antihypertensive therapy, and the systematic use of painkillers was
initiated. In the last month, the pulsatile mass increased and so did
the pain intensity. On this occasion, the clinician had already diagnosed
abdominal aortic aneurysm (AAA) by way of clinical examination and abdominal
echography. The plain chest x-ray showed remarkable enlargement of the
thoracic aorta, but no chest pain was reported.
In the last week, the patient complained of unrelenting pain, for which
opioid analgesia was used. We assessed the patient as to the possibilities
of treatment, although he had been regarded as surgically intractable
due to the severity of the disease.
An abdominal CT-scan was performed, revealing thoracic aortic dissection
sequelae, with double lumen from the upper portion of the aorta to the
juxtarenal abdominal aorta. The diameter of the aorta ranged from 6.5
cm PA to 5.5 cm T at the level of the thoracic aorta (Figure 1), 5 cm
x 7 cm at the thoracoabdominal transition level (Figure 2), 6 x 5 cm
at the level of the left renal vein (Figure 3), and 9 x 17 cm in the
medial aortic portion (Figure 4). The diameter of iliac arteries was
5 cm on the right and 4.5 cm on the left side. There were signs of blood
extravasation at the height of the left aortoiliac transition and of
vertebral body erosion as well.
Figure
1- Abdominal aortic aneurysm with 6.5 cm x 5.5 cm at the level of the
thoracic aorta.
Figure
2- Abdominal aortic aneurysm with 5 cm x 7 cm at the thoracoabdominal
transition level.
Figure
3- Abdominal aortic aneurysm with 6 cm x 5 cm at the level of the left
renal vein.
Figure
4- Abdominal aortic aneurysm with 9 cm x 17 cm in the medial aortic
portion.
The diagnosis
of ruptured, sealed, large and expansive aneurysm, with AAD sequelae
and refractory pain constituted a great therapeutic challenge.
What were the most relevant problems?
1.The patient needs to be operated on, but what are the risks of this
procedure?
2.Are there any other alternatives?
3. Should a thoraco-phreno-laparotomy be performed for complete resolution
of the problem?
4. Should the surgery be restricted to the region of the abdominal aorta
and iliac arteries?
5. If such strategy were to be adopted, what device would be used for
replacement of the abdominal and iliac aorta, given that the diameter
of the aorta is 6 x 5 cm at the level of the renal vein?
6. What would you do, considering that the patient had a cardiac and
renal reserve that allowed for the necessary surgical procedure?
