repair of a ruptured AAA2 and one case of endoluminal exclusion of a traumatic aortic rupture3 have been reported in the literature. Fig. 1. Abdominal CT scan ...
Eur J Vasc Endovasc Surg 19, 202–204 (2000) doi:10.1053/ejvs.1999.0981, available online at http://www.idealibrary.com on
ENDOVASCULAR AND SURGICAL TECHNIQUES
Contained Rupture of an Infrarenal Abdominal Aortic Aneurysm Treated by Endoluminal Repair M. H. Seelig∗1, C. Berchtold1, P. Jakob2 and K. Scho¨nleben1 1
Department of Surgery and 2Institute of Roentgenology, General Hospital Ludwigshafen, Bremserstrasse 79, D-67063 Ludwigshafen am Rhein, Germany Introduction
Endovascular repair of abdominal aortic aneurysms (AAAs) has evolved dramatically within the last few years. Given the potential to reduce morbidity and mortality associated with open surgical repair, endoluminal grafting offers therapeutic options to patients who are not surgical candidates due to their co-morbidities.1 In the presence of a ruptured AAA with a haemodynamically unstable patient, endoluminal repair is contraindicated at present. However, in a haemodynamically stable patient with a contained retroperitoneal rupture, endoluminal repair may be an option. So far, only one case of an endoluminal repair of a ruptured AAA2 and one case of endoluminal exclusion of a traumatic aortic rupture3 have been reported in the literature. Fig. 1. Abdominal CT scan demonstrating an infrarenal abdominal aortic aneurysm with retroperitoneal rupture.
Case Report A 58-year-old man experienced sudden lower back pain with radiation into the lower abdomen. In the following 2 days he was treated by his general practitioner and orthopaedic surgeon for a supposed nuclear protrusion. An abdominal ultrasound revealed an infrarenal AAA. An abdominal CT scan subsequently demonstrated a 7-cm infrarenal aneurysm with a contained retroperitoneal rupture (Fig. 1). At this time the patient was haemodynamically stable with a blood pressure of 160/90 mmHg, a heart rate of 95/min and a haemoglobin of 14.1 g/dl. All peripheral pulses were ∗ Please address all correspondence to: M. H. Seelig, Department of Surgery, General Hospital Ludwigshafen, Bremserstr. 79, D-67063 Ludwigshafen/Rhein, F.R.G. 1078–5884/00/020202+03 $35.00/0 2000 Harcourt Publishers Ltd.
present. Since the patient had severe coronary artery disease and compensated heart failure, he was transferred to our hospital immediately for emergency endoluminal or conventional repair. On arrival, the patient was haemodynamically stable with a blood pressure of 140/90 and a rate of 90/min. A repeated blood count revealed a drop of his haemoglobin to 11.9 g/dl. The patient was transferred immediately to the angiography suite. Under H1- and H2-receptor blockage with 8 mg dimetindenmaleate and 800 mg cimetidine IV due to a known contrast allergy, angiography via the right common femoral artery with a calibrated catheter was performed. This revealed normal renal arteries and a large infrarenal AAA beginning 2 cm below the orifices of the renal arteries
Endoluminal Repair of Ruptured Infrarenal AAA
Fig. 2. Angiography of the infrarenal aorta. The proximal neck is 2 cm long and has a diameter of 1.8 cm (A). In addition a small aneurysm of the right internal iliac artery is noted (B).
and extending to the bifurcation. In addition, a small aneurysm of the right common iliac artery was noted (Fig. 2). The 6-French introducer was left in place and the patient was taken to the operating room. After induction of general anaesthesia and draping as for conventional repair, an incision was made in the right groin for vascular access to the femoral artery. After insertion of a guidewire and determination of the lowest renal artery by angiography, a bifurcated stent graft (165×24×12 mm; Vanguard, Boston Scientific, Oakland, NJ, U.S.A.) was inserted. The contralateral iliac graft was inserted percutaneously via the left groin. At the end of the procedure, angiography demonstrated no leak. The patient was transferred to the intensive care unit (ICU) for 3 days. After systemic anticoagulation with heparin for 3 days, he received acetylsalicylic acid, 100 mg per day. A spiral CT scan of the abdomen 12 days after the operation disclosed a small leak at the anastomosis between the main prosthesis and the left limb. The aneurysmal sac was almost completely thrombosed. A contrast-enhanced spiral computed tomography (CT) scan 4 and 15 months after the operation demonstrated no leak and a reduction of
the maximal diameter of the aneurysmal sac from 63 mm to 50 mm.
Discussion Operative repair of ruptured AAA is associated with an operative mortality between 25% and 60%.4,5 Since many patients never reach the hospital, the mortality may be much higher. Endoluminal repair of AAA, however, needs an accurate determination of the aneurysmal morphology with CT and angiography with a calibrated catheter and is therefore not suitable for a haemodynamically unstable patient. Our patient was haemodynamically stable, and a bifurcated stent graft of appropriate size was available. We therefore decided to perform angiography which confirmed that the morphology of the aneurysm was suitable for endoluminal repair. Although a small anastomotic leak at the left limb with retrograde flow into an almost completely thrombosed aneurysm was detected on the postoperative CT scan, we felt that no additional intervention was Eur J Vasc Endovasc Surg Vol 19, February 1999
M. H. Seelig et al.
follow-up 4 months after the operation, the diameter of the aneurysm sac was 63 mm, the perianeurysmal haematoma was resolved, and the aneurysmal sac was completely thrombosed. At follow-up 15 months after the operation the aneurysmal sac was reduced by 13 mm to 50 mm. For the moment, endoluminal repair of ruptured AAA only seems applicable in selected haemodynamically stable patients. Conversion to a conventional repair may be required during the procedure and should be performed without delay if the patient becomes unstable. Whilst open surgery still remains the treatment of choice in the haemodynamically unstable patient with a ruptured AAA, we have demonstrated that – in auspicious circumstances – endoluminal treatment can be successfully performed.
Fig. 3. CT scan with intravenous contrast and coronal reconstruction 15 months after the operation demonstrates correct placement of the prosthesis with no flow in the aneurysmal sac.
indicated at this time. As in our case, these leaks are usually not haemodynamically significant and may become sealed by thrombosis within a short period of time, accompanied by shrinking of the aneurysm.6 At
Eur J Vasc Endovasc Surg Vol 19, February 1999
1 Blum U, Voshage G, Lammer J et al. Endoluminal stent grafts for infrarenal abdominal aortic aneurysms. N Engl J Med 1997; 336: 13–20. 2 Scharrer-Palmer R, Gorich J, Orend KH, Sokiranski R, Sunder-Plassmann L. Emergent endoluminal repair of delayed abdominal aortic rupture after blunt trauma. J Endovasc Surg 1998; 5: 134–137. 3 Yusuf SW, Whitaker SC, Chuter TA, Wenham PW, Hopkinson BR. Emergency endovascular repair of leaking aortic aneurysm (Letter). Lancet 1994; 344: 1645. 4 Van Dongen HP, Leusink JA, Moll FL, Brons FM, de Boer A. Ruptured abdominal aortic aneurysms: factors influencing postoperative mortality and long-term survival. Eur J Vasc Endovasc Surg 1998; 15: 62–66. 5 Halpern VJ, Kline RG, D’Angelo AJ, Cohen JR. Factors that affect the survival rate of patients with ruptured abdominal aortic aneurysms. J Vasc Surg 1997; 26: 939–945. 6 White RA, Donayre CE, Walot I et al. Regression of an abdominal aortic aneurysm after endograft exclusion. J Vasc Surg 1997; 26: 133–137. Accepted 1 July 1999