Late Rupture of a Totally Thrombosed Abdominal Aortic Aneurysm: A Case Report and Literature Review

EVAR Solution After an Acutely Thrombosed Abdominal Aortic Aneurysm in a Patient with COVID-19

Introduction

Acute thrombosis of an infrarenal abdominal aortic aneurysm (ATAAA) represents an uncommon but catastrophic pathology, which can lead to life threatening complications. This is a report of the infrequent use of an endovascular solution to successfully treat ATAAA in a patient with COVID-19 viral pneumonia and ischaemia induced lower extremity neurological deficits.

Report

An 89 year old white male, with a history of cardiovascular comorbidities was admitted to the emergency room with dyspnoea associated with the sudden onset of abdominal and back pain followed by partial motor and sensory deficits in both legs. The CT scan showed both an 8 cm infrarenal AAA with middle (inferior mesenteric artery patent) and distal thrombotic occlusion of the sac and non-aneurysmal but thrombosed common iliac arteries. An additional finding was imaging features typical of interstitial pneumonia. After the molecular test detected active COVID-19 infection, the patient was treated as an emergency with an aorto-uni-iliac stent graft and femorofemoral crossover graft. The post-operative course was uneventful with AAA exclusion and disappearance of ischaemic symptoms. There were no vascular complications. At three month follow up the patient remained asymptomatic and was looking after himself.

Discussion

This case supports the feasibility and safety of a minimally invasive endovascular procedure to treat ATAAA in selected patients with favourable anatomy and high risk of respiratory complications in the context of the COVID-19 pandemic.

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Acute thrombosis of an abdominal aortic aneurysm is an uncommon condition.

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It can be life threatening, particularly in high surgical risk patients.

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In this case, a potential cause may have been a coagulation disorder from COVID-19.

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In COVID-19, lower ICU resource use and shorter hospital stay are essential.

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Endovascular repair should be considered in anatomically suitable patients.

Acute Thrombosis of an Infrarenal Abdominal Aortic Aneurysm Presenting as Bilateral Critical Lower Limb Ischemia

BACKGROUND

Intraluminal thrombosis in the aneurysm sac is commonly seen in abdominal aortic aneurysm (AAA). Complete acute thrombosis of an AAA is a rare and catastrophic event.

METHOD

We report a patient with acute AAA thrombosis presenting as bilateral lower limbs critical ischemia. A79-year-old male with a past history of AAA presented with acute onset of bilateral leg pain, coolness, weakness and numbness. His lower extremity pulses including femorals were absent bilaterally on physical examination. Urgent computed tomography angiography showed an infrarenal AAA measuring 45 mm in diameter. The aneurysm sac and bilateral common iliac arteries were completely occluded. Emergency open repair of AAA and bilateral iliac thrombectomy were successfully performed under general anesthesia.

RESULT

Bilateral femoral pulses were present and the neurological deficits were completely resolved after operation. Patient recovered well and was asymptomatic at 3-month follow-up.

CONCLUSION

Acute thrombosis of aortic aneurysm could be an unusual cause of lower limb ischemia, prompt diagnosis followed by surgical revascularization is essential to avoid prolonged ischemia.

Endovascular Treatment of a Chronically Thrombosed Abdominal Aortic Aneurysm: Technical Considerations

BACKGROUND

Chronic thrombosis of an abdominal aortic aneurysm (AAA) is a rare entity and the ideal management is debatable.

METHODS AND RESULTS

A 74-year-old man presented with an enlarging chronically thrombosed AAA and incapacitating bilateral claudication, worse on the left side. We opted for an endovascular approach. Under local anesthesia and via a left axillary and left femoral cutdown, an aorto-uni-iliac stent graft (Endurant, Medtronic) was implanted down the left common iliac artery. A femorofemoral crossover bypass was not necessary because the right leg circulation was considered adequate on completion of the endovascular procedure. He had an uneventful recovery. His left leg symptoms were completely resolved and he was able to walk with only moderate right leg claudication after 300-400m.

CONCLUSIONS

Endovascular treatment of a chronically thrombosed AAA can be performed under local anesthesia and is a safe alternative to open surgery in high-risk patients. The long-term results need further investigation.

Rupture of a Totally Occluded Abdominal Aortic Aneurysm

Totally occluded aortic aneurysm is a rare pathology. The medical history and the evolution are unknown. We present a case of a regularly followed up 60-year-old man with chronic thrombosed aneurysm, presenting with mycotic acute rupture. As an original treatment, the patient was treated by aortic ligation without distal revascularization. A literature review from 1974 to 2015 enhances the contemporary understanding of the pathology, by exploring the thrombus interaction, pressure, and the wall shear stress. The literature review confirms the poor prognosis and concludes of a necessary closer follow-up for chronic occluded aneurysm.