Back
pain and infrarenal abdominal aortic aneurysm
(Portuguese
PDF version)
Telmo
P. Bonamigo,1 Nilon Erling Jr.,2 Marcela Salles3
1.
Adjunct professor of vascular surgery, Fundação Faculdade
Federal de Ciências Médicas de Porto Alegre (FFFCMPA).
Chief of the service of vascular surgery, Santa Casa de Misericórdia
de Porto Alegre, RS, Brazil.
2. Resident of vascular surgery, Santa Casa de Misericórdia
de Porto Alegre, RS, Brazil.
3.
Cardiovascular surgeon, service of cardiac surgery, Hospital São
Francisco, Santa Casa de Misericórdia de Porto Alegre, RS,
Brazil.
Correspondence:
Nilon Erling Jr.
Rua João Teles, 280/603
CEP 90035-120 - Porto Alegre, RS, Brazil
Phone: +55 (51) 3311.4381/9116.9019
E-mail: nilon.voy@terra.com.br
J Vasc
Br 2004;3(4):407-9
With the
hypothesis of expansion and/or contained rupture of a thoracoabdominal
aneurysm in mind, a thoracic CT scan was required, and it later confirmed
our clinical suspicion (Figure 4).
Figure
4 - Thoracic tomography scan showing the aorta with a contained
hematoma on the right (arrow).
As the
diagnosis was confirmed and the patient was hemodynamically stable,
she was admitted to the Intensive Care Unit (ICU) and prepared to undergo
surgery. The spinal cord was protected with an intradural catheter for
liquor drainage, and hemodynamic monitoring was obtained by Swan-Ganz
catheterization.
The thoraco-phreno-laparotomy
was the surgical approach of choice. Clamping was made in the mid third
of the descending thoracic aorta and in the common iliac arteries. A
bio pump device was used to bypass the left atrium to the left femoral
artery. We proceeded with longitudinal aneurysmectomy (Figure 5), infusion
of cold physiological solution in the visceral arteries and proximal
implantation of a 26 mm straight Dacron graft. The reimplantation of
the celiac trunk, right renal artery and superior mesentery artery was
made in the lateral graft face, with a continuous suture in 48 minutes
of clamping. The left renal artery was reimplanted in 60 minutes of
ischemia. The straight Dacron tube was anastomosed to a bifurcated Dacron
graft of 16 x 8 mm, allowing for the anastomosis of the left branch
of the common femoral artery, and the right branch of the external iliac
artery (Figure 6). The total procedure lasted 330 minutes. There was
2,200 ml of blood loss, of which 1,200 ml were re-induced by the cell
saver device. Four units of red cells and two units of plasma were also
transfused. Drains were inserted in the left pleural space, and in the
left flank.
Figure
5 - Intraoperative picture of the thoracic aortotomy showing posterolateral
rupture with hematoma (arrow).
Figure
6 - Surgical detail of the straight Dacron graft implanted in the
thoracic aorta (black arrow); implantation of the viscera vessels (white
arrow); anastomosis with bifurcated graft (arrow head) that allowed
for a distal implant in the right iliac and left femoral arteries.
The patient
had a good postoperative recovery and was extubated within the first
24 hours. In the neurological examination performed on the second postoperative
day, the patient presented a slight decrease of proximal strength in
the right lower limb. The intradural catheter drained 600, 560, 200,
and 50 ml/day of liquor, and it was maintained up to the fourth postoperative
day. The patient had a progressive improvement of the neurological deficit;
she started walking on the fifth postoperative day, and was then discharged
from the ICU. Table 1 shows the evolution of the volume of liquid drained
during the ICU stay. She maintained a good urine volume, although there
was a transient increase in the serum creatinine level to 2.1 mg/dl
in the second postoperative day. In the seventh day the level returned
to 1 mg/dl.
Table
1 - Post-operative draining volume (in ml)
 |
| |
1° PO |
2°
PO |
3°
PO |
4°
PO |
5°
PO |
|
| Urine
volume |
1.570
|
1.050 |
1.400 |
2.550 |
2.950 |
| L
pleural draining |
192
|
174
|
127
|
149
|
20 |
| Liquor
draining |
600
|
560
|
200
|
50 |
- |
| L
flank draining |
170 |
- |
- |
- |
- |
|
L
= left
The patient
was discharged uneventfully in the 10th postoperative day.
Follow-up
made with angioresonance imaging (Figures 7 and 8) shows the anastomosis
of the terminal aorta with the combination of a straight graft (proximal)
and a bifurcated graft (distal). The left renal artery is not permeable,
in spite of being reimplanted.
Figure
7 - Postoperative angiotomography showing the proximal anastomosis
(arrow) in the thoracic aorta.
Figure
8 - Postoperative angiographic computed tomography showing the viscera
repair in the straight graft and the anastomosis with the bifurcated
graft.
The case
reported here demonstrates how important it is to think beyond what
is firstly presented when the surgeon is required to provide a consultant
opinion.
In the
case described, the characteristics of the back pain were not compliant
with the infrarenal AAA. The vascular surgeon concluded that the cause
of the pain should be diagnosed, regardless of the presence of the AAA.
The tomography scan of the thorax showed the contained rupture of the
descending aorta, allowing the prescription of the right treatment,
which was the simultaneous repair of the thoracoabdominal and infrarenal
aneurysms.
If the
patient had been given treatment only for the infrarenal AAA, the contained
thoracic aorta rupture would lead to the maintenance of the symptoms
and expansion of bleeding, and an even more complex and urgent surgical
procedure would be required to avoid death.
The use
of liquor drainage must be emphasized, as the patient had a neurological
deficit that would be definitive if drainage was not performed. The
use of the general safety provided by the bio pump system should not
be disregarded in procedures like this one.
The patient
remains asymptomatic, with normal renal function, walking and attending
clinical follow-up at every 6 months.
The clinical
case we presented here has features concerned to two medical challenges:
diagnosis and therapy. The goal of this report was to call the attention
to the importance of details that are responsible for therapeutic challenges.
