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):284
We considered
that the unremitting and intense pain was caused by acute expansion
of the aneurysm with sealed rupture and vertebral body erosion. Therefore,
despite anatomical difficulties, the procedure had to be successful.
The first difficulty concerned the left renal vein, which prevented
the isolation of the infrarenal portion. As the left kidney was atrophic,
this vein was simply sectioned and ligated. This maneuver allowed for
a better surgical field.
The second difficulty was to match the disproportionate diameter of
the juxtarenal aorta with the diameter of the prosthesis, whose diameter
measured 30 mm (bovine pericardium graft coated with Dacron) (Figure
5). We widened the "opening" of the prosthesis with two 0.7
cm longitudinal incisions, made in opposite positions. After the clamping
of the juxtarenal aorta, we performed an aortic dissection and removed
a large number of thrombi; we also identified erosion of two vertebral
bodies and a remarkable fibrous reaction in this area. After that, by
compressing the proximal aorta, we sectioned approximately one centimeter
of the dissection septum found at the level of the renal artery. We
immediately performed a proximal anastomosis, which resulted in appropriate
adjustment between the extremities. A straight graft was used in an
extension of 5 cm, and in the distal portion a bifurcated graft measuring
22 x 11 mm was anastomosed (bifurcated bovine pericardium graft coated
with Dacron) (Figure 6), evening out the discrepancy in diameters. The
right-side distal anastomosis was performed on the external iliac artery
and the left-side anastomosis was carried out on the common femoral
artery (Figure 7).
Figure
5 - Bovine pericardium graft coated with Dacron, 30 mm.
Figure
6 - Bifurcated bovine pericardium graft coated with Dacron, 22 mm x
11 mm.
Figure
7 - Right-side distal anastomosis on the common femoral artery.
We concluded
the procedure, during which we used 870 ml of blood recycled by Cell
Saver and 2 U of CHAD [não encontrei essa sigla nem em inglês
nem em português - não sei o que significa], in addition
to 4,000 ml of saline solution, 4,000 ml of dextrose saline and 250
ml of mannitol. Aortic clamping lasted 51 minutes. Intraoperative urine
volume was 350 ml and the length of the surgery was 4 hours and 15 minutes.
The immediate postoperative period was free of any major intercurrent
complications. The patient was monitored at an intensive care unit for
72 hours, showing good hemodynamic stability and controlled arterial
blood pressure. Persistent febricula (37.8°C to 38.2°C) was
present during nine days, and treated with prophylactic antibiotics
in the first 48 hours, but no leukocytosis, sepsis or other local infectious
complications were found. The patient was discharged, with normal cardiac,
respiratory, abdominal and renal functions, and a mild abdominal pain.
One week after discharge, the fever persisted and a new abdominal CT-scan
was performed. This exam revealed a probably serous collection between
the implanted aortic prosthesis and the original aortic wall. Since
no other clinical sign that could justify the persistent fever was found,
we decided to perform a CT-guided puncture for diagnostic purposes;
a clear serous fluid was obtained, but its culture did not show any
microorganisms or leukocytes. Both oxacillin and ciprofloxacin were
given from the moment of the puncture to the time of the results. A
new control CT-scan after 72 hours showed recurrence of seroma with
a milder intensity, and a new puncture was made for drainage. Ever since,
there was clinical improvement and normalization of the thermal curve,
and we decided to keep the patient on oral ciprofloxacin for 28 days,
due to the risk of prosthesis infection after manipulation. No fever
or any other complication occurred, and the patient was discharged after
being prescribed antihypertensive drugs and acetylsalicylic acid. He
went back to his usual daily activities, and did not require special
medical care regarding his aortic problems. He was followed up for control
of the arterial blood pressure and atherosclerotic disease risk factors
in the following years.
The patient came back in 2002 with acute chest pain due to the expansion
of the thoracic aneurysm, which basically affected the whole left hemithorax,
and also had reduced left ventricle function (LVEF = 35%). After discussing
the case with the medical staff, we decided that a surgical procedure
would be dangerous, and we therefore opted for the conservative treatment.
The patient and his family agreed to the treatment. The patient continued
receiving painkillers, but died a few weeks later due to aneurysm rupture.
Figure
8 - Thoracic aortography showing the beginning of the dissection and
the expanded aneurysm.
Figure
9 - Dilation in the thoracoabdominal transition and the initial portion
of the previous normal abdominal graft.
