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Endovascular aneurysm repair in emergent ruptured abdominal aortic aneurysm with a 'real' hostile neck and severely tortuous iliac artery of an elderly patient.

Wu N, Liu C, Fu Q, Zeng R, Chen Y, Yang G, Liu B - BMC Surg (2014)

Bottom Line: A 79-year-old woman presented as an emergency of abdominal pain with acute hypotension, heart rate elevation and a rapid decrease of hemoglobin.Two iliac legs were placed superior to the opening of the right hypogastric respectively.She is well and symptom-free 6 months later.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of vascular surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No, 1 Shuaifuyuan, Beijing 100730, P,R, China. dr.liubao@gmail.com.

ABSTRACT

Background: Endovascular aneurysm repair (EVAR) has been a revolutionary development in the treatment of abdominal aortic aneurysms (AAAs). Meanwhile, unfavorable anatomy of the aneurysm has always been a challenge to vascular surgeons, and the application of EVAR in emergent and elderly patients are still in dispute.

Case presentation: A 79-year-old woman presented as an emergency of abdominal pain with acute hypotension, heart rate elevation and a rapid decrease of hemoglobin. Emergent computed tomographic angiography (CTA) showed a ruptured AAA (rAAA) extending from below the opening of bilateral renal arteries down to the celiac artery and elongated to both common iliac arteries. The hostile neck and severely tortuous iliac artery made the following procedure a great challenge. An emergent endovascular approach was performed in which an excluder aortic main body was deployed below the origin of the bilateral renal arteries covering the ruptured aortic segment. Two iliac legs were placed superior to the opening of the right hypogastric respectively. In order to avoid the type Ib endoleak, we tried to deploy another cuff above the bifurcation of the iliac artery. However, the severely tortuous right iliac artery made this procedure extremely difficult, and a balloon-assisted technique was used in order to keep the stiff wire stable. Another iliac leg was placed above the bifurcation of the left iliac artery. The following angiography showed a severe Ia endoleak in the proximal neck and therefore, a cuff was deployed distal to opening of the left renal artery with off-the-shelf solution. The patient had an uneventful recovery with a resolution of the rAAA. She is well and symptom-free 6 months later.

Conclusion: Endovascular aneurysm repair (EVAR) in emergent elderly rAAA with hostile neck and severe tortuous iliac artery is extremely challenging, and endovascular management with integrated technique is feasible and may achieve a satisfactory early result.

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Related in: MedlinePlus

Preoperative CTA and 3-dimensional reconstructions. (A) Preoperative CTA shows a ruptured AAA with a maximum diameter of 10.33 cm in axial view. (B, C) 3-dimensional reconstructions confirmed the rupture extended from 2.5 cm below the level of right renal artery down to the celiac artery. A sever tortuous right celiac artery was observed with a ‘S’ appearance.
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Figure 1: Preoperative CTA and 3-dimensional reconstructions. (A) Preoperative CTA shows a ruptured AAA with a maximum diameter of 10.33 cm in axial view. (B, C) 3-dimensional reconstructions confirmed the rupture extended from 2.5 cm below the level of right renal artery down to the celiac artery. A sever tortuous right celiac artery was observed with a ‘S’ appearance.

Mentions: A 79-year-old woman was admitted to the emergency department of Peking Union Medical College Hospital complaining of severe abdominal pain with unknown causes for 4 hours. The pain got worse after 2 hours with an acute hypotension (blood pressure drop from 106/79 mmHg to 61/44 mmHg), heart rate elevation (from 80 beats/min to 100 beats/min) and blunted. Laboratory investigation noted a decrease of hemoglobin from 119 g/dL to 62 g/dL in half an hour. Emergent computed tomographic angiography (CTA) showed the presence of a very tortuously ruptured AAA that now was 10.33 cm in diameter with a 90° neck angle (Figure 1A). The rupture, which extended from 2.5 cm below the opening of bilateral renal arteries down to the celiac artery and elongated to both common iliac arteries, involved the inferior mesenteric artery. Although the two iliac arteries were unobstructed with a 2.1 cm and 1.8 cm diameter of the right and left respectively, the right iliac artery was severely tortuous with a ‘S’ appearance (Figure 1B and C).


Endovascular aneurysm repair in emergent ruptured abdominal aortic aneurysm with a 'real' hostile neck and severely tortuous iliac artery of an elderly patient.

Wu N, Liu C, Fu Q, Zeng R, Chen Y, Yang G, Liu B - BMC Surg (2014)

Preoperative CTA and 3-dimensional reconstructions. (A) Preoperative CTA shows a ruptured AAA with a maximum diameter of 10.33 cm in axial view. (B, C) 3-dimensional reconstructions confirmed the rupture extended from 2.5 cm below the level of right renal artery down to the celiac artery. A sever tortuous right celiac artery was observed with a ‘S’ appearance.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4016293&req=5

Figure 1: Preoperative CTA and 3-dimensional reconstructions. (A) Preoperative CTA shows a ruptured AAA with a maximum diameter of 10.33 cm in axial view. (B, C) 3-dimensional reconstructions confirmed the rupture extended from 2.5 cm below the level of right renal artery down to the celiac artery. A sever tortuous right celiac artery was observed with a ‘S’ appearance.
Mentions: A 79-year-old woman was admitted to the emergency department of Peking Union Medical College Hospital complaining of severe abdominal pain with unknown causes for 4 hours. The pain got worse after 2 hours with an acute hypotension (blood pressure drop from 106/79 mmHg to 61/44 mmHg), heart rate elevation (from 80 beats/min to 100 beats/min) and blunted. Laboratory investigation noted a decrease of hemoglobin from 119 g/dL to 62 g/dL in half an hour. Emergent computed tomographic angiography (CTA) showed the presence of a very tortuously ruptured AAA that now was 10.33 cm in diameter with a 90° neck angle (Figure 1A). The rupture, which extended from 2.5 cm below the opening of bilateral renal arteries down to the celiac artery and elongated to both common iliac arteries, involved the inferior mesenteric artery. Although the two iliac arteries were unobstructed with a 2.1 cm and 1.8 cm diameter of the right and left respectively, the right iliac artery was severely tortuous with a ‘S’ appearance (Figure 1B and C).

Bottom Line: A 79-year-old woman presented as an emergency of abdominal pain with acute hypotension, heart rate elevation and a rapid decrease of hemoglobin.Two iliac legs were placed superior to the opening of the right hypogastric respectively.She is well and symptom-free 6 months later.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of vascular surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No, 1 Shuaifuyuan, Beijing 100730, P,R, China. dr.liubao@gmail.com.

ABSTRACT

Background: Endovascular aneurysm repair (EVAR) has been a revolutionary development in the treatment of abdominal aortic aneurysms (AAAs). Meanwhile, unfavorable anatomy of the aneurysm has always been a challenge to vascular surgeons, and the application of EVAR in emergent and elderly patients are still in dispute.

Case presentation: A 79-year-old woman presented as an emergency of abdominal pain with acute hypotension, heart rate elevation and a rapid decrease of hemoglobin. Emergent computed tomographic angiography (CTA) showed a ruptured AAA (rAAA) extending from below the opening of bilateral renal arteries down to the celiac artery and elongated to both common iliac arteries. The hostile neck and severely tortuous iliac artery made the following procedure a great challenge. An emergent endovascular approach was performed in which an excluder aortic main body was deployed below the origin of the bilateral renal arteries covering the ruptured aortic segment. Two iliac legs were placed superior to the opening of the right hypogastric respectively. In order to avoid the type Ib endoleak, we tried to deploy another cuff above the bifurcation of the iliac artery. However, the severely tortuous right iliac artery made this procedure extremely difficult, and a balloon-assisted technique was used in order to keep the stiff wire stable. Another iliac leg was placed above the bifurcation of the left iliac artery. The following angiography showed a severe Ia endoleak in the proximal neck and therefore, a cuff was deployed distal to opening of the left renal artery with off-the-shelf solution. The patient had an uneventful recovery with a resolution of the rAAA. She is well and symptom-free 6 months later.

Conclusion: Endovascular aneurysm repair (EVAR) in emergent elderly rAAA with hostile neck and severe tortuous iliac artery is extremely challenging, and endovascular management with integrated technique is feasible and may achieve a satisfactory early result.

Show MeSH
Related in: MedlinePlus