CASE PRESENTATION
A 63-year-old male was presented tο the Emergency Department in
haemo-dynamic shock (BP 85/55mmHg, HR 117bpp, anuria).
Patient symptoms began six days ago, with abdominal pain, localized in
the lumbar area. The pain appeared suddenly and was followed by an
episode of haematochesia. Ever since, the patient reports repeated
bleedings per rectum (PR) and a fever up to 38.9 oC
degrees.
Prior medical history included hypertensive cardiopathy, diverticulitis,
open repair of abdominal aortic aneurysm (AAA) 10 years ago and plastic
reconstruction of postoperative abdominal midline hernia a year ago.
After primary fluid resuscitation an abdominal CT scan was ordered, in
which a mass was depicted alongside distal aortic anastomosis of the
previous tube synthetic graft. (Figures 1- 2).
In the contrast enhanced CT scan, active extravasation is visible at the
same level of the aortic graft into a sac containing attenuating clot
and ectopic gas. (Figure 3).
The patient was, thereby, lead to the OR, where a ruptured distal
anastomosis of his previous AAA repair was found indeed and under direct
Fluoroscopy an endovascular aortic aneurysm repair (EVAR) with the use
of a bifurcated stent graft placement over the rupture occurred.
Intraoperative completion angiography confirmed satisfactory placement
of the stent and no leaks or endoleaks were identified along with
simultaneous hemodynamic stability of the patient.
Five days postoperative, a repeated CTA was done, exhibiting
satisfactory placing of the stent, total sealing of the rupture with no
signs of leakage at the periaortic region or inside the bowel. (Figure
4)
The patient’s postoperative period was uneventful and in seventh day
postop he was driven again to the OR where a wide surgical debridement
with sigmoidectomy and Hartmann procedure took place.
Postoperative period was uneventful, infection markers normalized, and
the patient presented no signs of fatigue or fever.
The patient recovered well and was discharged 16 days postoperatively,
after the consultation of the Infections Disease Experts Committee, for
a six weeks protocol of antibiotic treatment.
Three months later returned to our clinic for a successful restoration
of the bowel continuity and at 6 and 12 months follow up the patient
remains in extraordinary condition with no reported complications and
completely regression of pseudoaneursym sac (Figures 5, 6).
Therefore he remains well with no signs of fatigue or fever, normal
infection markers and has totally returned to his previous activities
while he is monitored outpatient regularly.