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.