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Abdominal compartment syndrome after endovascular repair for ruptured abdominal aortic aneurysm leads to acute intestinal necrosis

View Article: PubMed Central - PubMed

ABSTRACT

Introduction:: Abdominal compartment syndrome (ACS) after endovascular repair (EVAR) of rupture abdominal aortic aneurysm (rAAA) is a rare emergency situation, which has a high mortality. However, the progression of ACS is rapid and the diagnosis is usually been delayed, which increase the difficulties in treatment and affect the prognosis. We describe a case of a sever complication (acute intestinal necrosis) resulting from ACS after endovascular repair of rAAA.

Clinical finding:: An elderly man, 81 years old, complained a sudden lower abdominal and back pain without any predisposing cause. He had a history of hypertension for 20 years without any regular anti-hypertensive therapy. Physical Examination revealed that the blood pressure was 89/54 mmHg, pulse was 120/min, oxygen saturation was 91%. The abdominal ultrasound and the CTA (computed tomography angiography) scan revealed a rAAA. Emergency EVAR under general anesthesia was performed for this patient.

Diagnosis:: Fourteen hours after endovascular repair, sudden decreased of blood pressure (70/50 mmHg) and oxygen saturation (70%) was observed. ACS or bleeding of retroperitoneal space was diagnosed.

Interventions:: Abdominal laparotomy was immediately performed. ACS was verified and a severe complication (acute intestinal necrosis) was observed, intestinal resection was performed for this patient.

Outcomes:: Unfortunately, this patient died after operation because of multi-organ failure in a very short period, which is very rare regarding to this condition. Surgical pathology, diagnosis and management were discussed.

Conclusion:: ACS was occurred with a severe complication (acute intestinal necrosis) in a very short period, which is very rare regarding to this condition after EVAR, it reminds us the severe result of ACS and more methods to prevent it happened after surgical management.

No MeSH data available.


Related in: MedlinePlus

Intraoperative appearance of intestinal necrosis.
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Figure 3: Intraoperative appearance of intestinal necrosis.

Mentions: After EVAR, this patient was sent to ICU with mechanically ventilation for postoperative care. Fourteen hours after EVAR, a sudden decrease of blood pressure (70/50 mm Hg) and oxygen saturation was observed (70%). At that time, this patient was still with mechanically ventilation and the patient was still unconscious. Physical examination revealed a distended abdomen with increased tension and weak bowel sound. Emergency blood values showed: Hb = 7.1 g/dL; WBC = 25.6 × 109/L; PLT = 37 × 109/L; INR = 1.43; ALT = 1097IU/L, AST = 1283IU/L, ALB = 23.7 g/L, Glu = 6.03 mmol/L, BUN = 12.13 mmol/L, Crea = 270 μmol/L, Na+ = 138.4 mmol/L, K+ = 6.12 mmol/L, Cl− = 99.5 mmol/L, Ca2+ = 1.81 mmol/L, Mg2+ = 1.03 mmol/L, Lac = 12.2 mmol/L, PO2 = 68 mm Hg, PCO2 = 35.3 mm Hg, PH = 7.30. Blood infusion and correction of metabolic acidosis were performed immediately and re-examination of blood value 1.5 hours later showed: Hb = 5.1 g/dL; WBC = 35.1 × 109/L; PLT = 30 × 109/L; INR = 1.51; ALT = 1061IU/L, AST = 1083IU/L, ALB = 21.7 g/L, Glu = 5.58 mmol/L, BUN = 10.13 mmol/L, Crea = 281 μmol/L, Na+ = 138.1 mmol/L, K+ = 5.62 mmol/L, Cl− = 94.5 mmol/L, Ca2+ = 1.91 mmol/L, Mg2+ = 1.13 mmol/L, Lac = 10.1 mmol/L, PO2 = 57 mm Hg, PCO2 = 38.3 mm Hg, PH = 7.377. The 2 possibilities of diagnosis were considered for this patient: ACS or bleeding of retroperitoneal space. Abdominal laparotomy was performed immediately to detect the reason for change in condition. Intraoperative exploration revealed that there was change in color of the intestinal wall ranging from distal of jejunum to proximal of ileum, the total length of the intestinal involvement was about 140 cm, no movement can be observed in this ischemia intestinal tube, no mesenterial vascular occlusion was observed (Fig. 3). A hematoma can be seen in the left retroperitoneal space without bleeding. There was no bleeding or endoleak in the aneurysmal sac (Fig. 4). The intestinal tube section did not change after warming with saline solution for 30 minutes, intestinal resection was performed finally for this patient, the total length of intestinal tube resected was about 160 cm (100 cm of jejunum and 60 cm of ileum separately), the ileocecal part was maintained for this patient. After operation, this patient was sent to ICU department with mechanically ventilation. Vital signs showed that blood pressure was 68/42 mm Hg under dopamine and noradrenalin, heart rate was 100/min, oxygen saturation was 87%. Re-examination of blood values showed: Hb = 7.9 g/dL; WBC = 8.46 × 109/L; PLT = 30 × 109/L; INR = 3.83; ALT = 1078IU/L, AST = 2527IU/L, ALB = 10.7 g/L, Glu = 3.03 mmol/l, BUN = 16.5mmol/L, Crea = 320 μmol/L, Na+ = 146.6 mmol/L, K+ = 4.51 mmol/L, Cl− = 102.3 mmol/L, Ca2+ = 3.80 mmol/L, Mg2+ = 0.83 mmol/L, Lac = 11.2 mmol/L, PO2 = 78 mm Hg, PCO2 = 41.4 mm Hg, PH = 7.366. A series of medical treatment including blood perfusion, anti-inflammation, correction of acidosis and hyperkalemia, mechanical ventilation were given to this patient. But the respiratory, liver and renal function deteriorated within 4 hours. The last blood values of this patient showed: Hb = 6.1 g/dL; WBC = 7.46 × 109/L; PLT = 21 × 109/L; INR = 5.92; ALT = 746IU/L, AST = 2163IU/L, ALB = 9.0 g/L, Glu = 3.22 mmol/L, BUN = 15.6 mmol/L, Crea = 323 μmol/L, Na+ = 146.9 mmol/L, K+ = 5.66 mmol/L, Cl− = 102.9 mmol/L, Ca2+ = 1.95 mmol/L, Mg2+ = 1.25 mmol/L, Lac = 13.6 mmol/L, PO2 = 55 mm Hg, PCO2 = 66.7 mm Hg, PH = 7.026, the blood pressure maintained about 65/40 mm Hg with dopamine and noradrenalin pumping, heart rate was 87/min, and oxygen saturation was about 87%. Finally, this patient eventually died due to the multiorgan failure in ICU department.


Abdominal compartment syndrome after endovascular repair for ruptured abdominal aortic aneurysm leads to acute intestinal necrosis
Intraoperative appearance of intestinal necrosis.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5134860&req=5

Figure 3: Intraoperative appearance of intestinal necrosis.
Mentions: After EVAR, this patient was sent to ICU with mechanically ventilation for postoperative care. Fourteen hours after EVAR, a sudden decrease of blood pressure (70/50 mm Hg) and oxygen saturation was observed (70%). At that time, this patient was still with mechanically ventilation and the patient was still unconscious. Physical examination revealed a distended abdomen with increased tension and weak bowel sound. Emergency blood values showed: Hb = 7.1 g/dL; WBC = 25.6 × 109/L; PLT = 37 × 109/L; INR = 1.43; ALT = 1097IU/L, AST = 1283IU/L, ALB = 23.7 g/L, Glu = 6.03 mmol/L, BUN = 12.13 mmol/L, Crea = 270 μmol/L, Na+ = 138.4 mmol/L, K+ = 6.12 mmol/L, Cl− = 99.5 mmol/L, Ca2+ = 1.81 mmol/L, Mg2+ = 1.03 mmol/L, Lac = 12.2 mmol/L, PO2 = 68 mm Hg, PCO2 = 35.3 mm Hg, PH = 7.30. Blood infusion and correction of metabolic acidosis were performed immediately and re-examination of blood value 1.5 hours later showed: Hb = 5.1 g/dL; WBC = 35.1 × 109/L; PLT = 30 × 109/L; INR = 1.51; ALT = 1061IU/L, AST = 1083IU/L, ALB = 21.7 g/L, Glu = 5.58 mmol/L, BUN = 10.13 mmol/L, Crea = 281 μmol/L, Na+ = 138.1 mmol/L, K+ = 5.62 mmol/L, Cl− = 94.5 mmol/L, Ca2+ = 1.91 mmol/L, Mg2+ = 1.13 mmol/L, Lac = 10.1 mmol/L, PO2 = 57 mm Hg, PCO2 = 38.3 mm Hg, PH = 7.377. The 2 possibilities of diagnosis were considered for this patient: ACS or bleeding of retroperitoneal space. Abdominal laparotomy was performed immediately to detect the reason for change in condition. Intraoperative exploration revealed that there was change in color of the intestinal wall ranging from distal of jejunum to proximal of ileum, the total length of the intestinal involvement was about 140 cm, no movement can be observed in this ischemia intestinal tube, no mesenterial vascular occlusion was observed (Fig. 3). A hematoma can be seen in the left retroperitoneal space without bleeding. There was no bleeding or endoleak in the aneurysmal sac (Fig. 4). The intestinal tube section did not change after warming with saline solution for 30 minutes, intestinal resection was performed finally for this patient, the total length of intestinal tube resected was about 160 cm (100 cm of jejunum and 60 cm of ileum separately), the ileocecal part was maintained for this patient. After operation, this patient was sent to ICU department with mechanically ventilation. Vital signs showed that blood pressure was 68/42 mm Hg under dopamine and noradrenalin, heart rate was 100/min, oxygen saturation was 87%. Re-examination of blood values showed: Hb = 7.9 g/dL; WBC = 8.46 × 109/L; PLT = 30 × 109/L; INR = 3.83; ALT = 1078IU/L, AST = 2527IU/L, ALB = 10.7 g/L, Glu = 3.03 mmol/l, BUN = 16.5mmol/L, Crea = 320 μmol/L, Na+ = 146.6 mmol/L, K+ = 4.51 mmol/L, Cl− = 102.3 mmol/L, Ca2+ = 3.80 mmol/L, Mg2+ = 0.83 mmol/L, Lac = 11.2 mmol/L, PO2 = 78 mm Hg, PCO2 = 41.4 mm Hg, PH = 7.366. A series of medical treatment including blood perfusion, anti-inflammation, correction of acidosis and hyperkalemia, mechanical ventilation were given to this patient. But the respiratory, liver and renal function deteriorated within 4 hours. The last blood values of this patient showed: Hb = 6.1 g/dL; WBC = 7.46 × 109/L; PLT = 21 × 109/L; INR = 5.92; ALT = 746IU/L, AST = 2163IU/L, ALB = 9.0 g/L, Glu = 3.22 mmol/L, BUN = 15.6 mmol/L, Crea = 323 μmol/L, Na+ = 146.9 mmol/L, K+ = 5.66 mmol/L, Cl− = 102.9 mmol/L, Ca2+ = 1.95 mmol/L, Mg2+ = 1.25 mmol/L, Lac = 13.6 mmol/L, PO2 = 55 mm Hg, PCO2 = 66.7 mm Hg, PH = 7.026, the blood pressure maintained about 65/40 mm Hg with dopamine and noradrenalin pumping, heart rate was 87/min, and oxygen saturation was about 87%. Finally, this patient eventually died due to the multiorgan failure in ICU department.

View Article: PubMed Central - PubMed

ABSTRACT

Introduction:: Abdominal compartment syndrome (ACS) after endovascular repair (EVAR) of rupture abdominal aortic aneurysm (rAAA) is a rare emergency situation, which has a high mortality. However, the progression of ACS is rapid and the diagnosis is usually been delayed, which increase the difficulties in treatment and affect the prognosis. We describe a case of a sever complication (acute intestinal necrosis) resulting from ACS after endovascular repair of rAAA.

Clinical finding:: An elderly man, 81 years old, complained a sudden lower abdominal and back pain without any predisposing cause. He had a history of hypertension for 20 years without any regular anti-hypertensive therapy. Physical Examination revealed that the blood pressure was 89/54 mmHg, pulse was 120/min, oxygen saturation was 91%. The abdominal ultrasound and the CTA (computed tomography angiography) scan revealed a rAAA. Emergency EVAR under general anesthesia was performed for this patient.

Diagnosis:: Fourteen hours after endovascular repair, sudden decreased of blood pressure (70/50 mmHg) and oxygen saturation (70%) was observed. ACS or bleeding of retroperitoneal space was diagnosed.

Interventions:: Abdominal laparotomy was immediately performed. ACS was verified and a severe complication (acute intestinal necrosis) was observed, intestinal resection was performed for this patient.

Outcomes:: Unfortunately, this patient died after operation because of multi-organ failure in a very short period, which is very rare regarding to this condition. Surgical pathology, diagnosis and management were discussed.

Conclusion:: ACS was occurred with a severe complication (acute intestinal necrosis) in a very short period, which is very rare regarding to this condition after EVAR, it reminds us the severe result of ACS and more methods to prevent it happened after surgical management.

No MeSH data available.


Related in: MedlinePlus