Asian Cardiovasc Thorac Ann 2008;16:e55-e57
© 2008 Asia Publishing EXchange Ltd
Chronic Contained Rupture of Abdominal Aortic Aneurysm
Hiroki Yokomuro, MD,
Yukio Ichikawa, MD,
Hirokazu Kajiwara, MD
Department of Cardiovascular Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
For reprint information contact: Hiroki Yokomuro, MD Tel: 81 45 701 9581 Fax: 81 45 701 9607 Email: hyokomuro{at}aol.com, 6-16-1 Tomioka-higashi, Kanazawaku, Yokohama 236-0051, Japan.
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ABSTRACT
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Computed tomography in a 74-year-old man with intermittent claudication revealed an abdominal aortic aneurysm, retroperitoneal hematoma, vertebral erosion, and total aortic occlusion. Surgery was delayed for 9 months after definitive diagnosis of contained rupture of the aortic aneurysm to allow treatment for ischemic heart disease and cardiac failure. After interposing a Y-shaped woven Dacron graft, the intermittent claudication was alleviated. The postoperative course was uneventful.
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INTRODUCTION
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Acute rupture of an abdominal aortic aneurysm (AAA) usually presents as severe abdominal pain and hemorrhagic shock. Chronic contained rupture of an AAA with a retroperitoneal hematoma and vertebral erosion, without the typical symptoms, has been described. This situation still poses a high risk of free rupture. Therefore, conservative observation for more than 6 months is associated with very high risk.1 We describe a case of chronic contained rupture that could not be surgically repaired for 9 months.
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CASE REPORT
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A 74-year-old man attended our hospital regularly for 6 years for follow-up of coronary bypass grafting 12 years previously at another hospital, arteriosclerosis obliterans, and chronic obstructive pulmonary disease. He developed intermittent claudication, and contrast-enhanced computed tomography revealed total occlusion at the terminal aorta (Figure 1
) and a retroperitoneal hematoma due to chronic ruptured AAA, with erosion of the 4th lumbar vertebra (Figure 2). Repair was postponed to allow a percutaneous coronary intervention for left anterior descending artery stenosis, and further delayed to treat cardiac failure that developed 5 months later. The patient was admitted for surgery 9 months after definitive diagnosis of contained AAA rupture. Physical examination revealed that he was afebrile, his blood pressure was 125/80 mm Hg, and his pulse rate was 70 beats·min–1. A non-pulsating mass was felt at the center of the abdomen. Both femoral arteries were impalpable. Laboratory data revealed mild anemia with hemoglobin of 12.1 g·dL–1 and a hematocrit of 35.5%. All biochemical tests were normal. Poor cardiac performance was revealed by echocardiography, with an ejection fraction of 38.6% and cardiac index of 1.9 L·min–1·m–2. A laparotomy was performed, and an AAA of 55-mm maximal diameter was incised after aortic cross clamping under the renal artery. After removing a full intraluminal thrombosis (Figure 3A), a punched-out defect measuring 30 x 25 mm was found on the posterior wall (Figure 3B), revealing a destroyed 4th vertebral body and a hematoma on the retroperitoneum. An infrarenal aortobifemoral Y-shaped woven Dacron graft (14 x 7 mm) was interposed. Bacterial culture of the excised aneurysm wall was negative. Surgery alleviated the intermittent claudication, and the ankle/brachial pressure index was 0.99 on the left side and 1.01 on the right side. The postoperative course was uneventful.
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Figure 1. Three-dimensional contrast-enhanced computed tomography showing total occlusion of the abdominal aorta to the bilateral common femoral arteries.
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Figure 2. (A) Axial and (B) sagittal abdominal computed tomography images showing the abdominal aortic aneurysm, peritoneal hematoma, and erosion of the 4th lumbar vertebra.
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Figure 3. Operative findings: (A) full intraluminal thrombosis (arrows), and (B) punched-out defect (arrows).
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DISCUSSION
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One type of AAA rupture is referred to as chronic, either contained or sealed.2,3 Chronic AAA rupture was first described by Szilagyi and colleagues4 in 1961. When a rupture occurs, the surrounding tissue may effectively seal off the bleeding, and a retroperitoneal hematoma can persist. Hemodynamic conditions remain stable because blood loss is slow.5 However, this situation is always associated with a high risk of free rupture, and should be surgically repaired within 6 months.1
Definite diagnosis of this type of rupture is sometimes delayed because it has various symptoms such as femoral disorders, intermittent claudication, lumbago, or obstructive jaundice with atypical symptoms.2,6,8 The computed tomography criteria for diagnosing this type of AAA are: discontinuity of the rim of calcification in the true aneurysmal wall; a well-defined soft tissue density adjacent to the aorta; concealed psoas muscle and displaced viscera, depending on the size of the lesion; and no appearance of the contrast material in the hematoma in some cases.7 This case could be diagnosed because of the first 3 criteria. Fortunately, this chronic contained rupture remained stable because of compression by the total aortic occlusion. Surgical treatment was necessary both to relieve the pain due to intermittent claudication and to avoid the possibility of rupture due to the punched-out defect. Even when the risk of rupture is low, the condition of such patients should be carefully monitored and the aorta repaired as soon as conditions allow.
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REFERENCES
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- Szilagyi DE. Clinical diagnosis of intact and ruptured abdominal aortic aneurysm. In: Bergan JJ, Yao JST, editors. Aneurysms: Diagnosis and Treatment. New York: Grune & Stratton, 1982:205–16.
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ABSTRACT
INTRODUCTION
