Chronic thrombosed abdominal aortic aneurysms: a report on three consecutive cases and literature review

Late Rupture of a Thrombosed Aortic Abdominal Aneurysm – a Case Report

Introduction: Severe back pain caused by a thrombosed and ruptured aortic abdominal aneurysm can imitate a lumbar disc herniation.

Case presentation: We present the case of a 72-year-old diabetic patient with chronic atrial fibrillation, who had been experiencing high-intensity low back pain and claudication in the last year prior to his presentation. After experiencing a minor trauma, a lumbar MRI examination was performed, which revealed a retroperitoneal tumoral mass compressing and eroding the L2–L4 vertebral bodies. Computed tomography angiography showed an infrarenal aortic aneurysm (3.374 × 3.765 cm) which appeared to have ruptured and thrombosed. The question arising was when did the rupture occur, how massive was the damage, and how suitable for reconstruction was the aortic wall below the origin of the renal arteries. An open repair was scheduled and performed. The intraoperative finding was ruptured aneurysm of the thrombosed infra-abdominal aorta. The thrombosis extended along the common iliac and external iliac branches. We performed an aortobifemoral bypass using a 16 × 8 mm Dacron graft, clamping the aorta above the origin of the renal arteries.

Conclusion: The unintentional diagnosis, due to a minor fall, was overall a fortunate event for this patient. Aortic aneurysms may present with lumbar pain that can be mistakenly interpreted as a spinal issue.

Acute Thromboembolism from Trauma in a Patient with Abdominal Aortic Aneurysm

Case Presentation

A 64-year-old man with a history of a 5.5-centimeter (cm) abdominal aortic aneurysm (AAA) presented to the emergency department (ED) complaining of severe back pain after climbing over a fence and falling a distance of eight feet. Prior to arrival, the prehospital paramedics reported that the patient did not have palpable pulses in either lower extremity. The initial physical examination in the ED was significant for absent dorsalis pedis pulses bilaterally as well as absent posterior tibialis pulses bilaterally and cold, insensate lower extremities. Point-of-care ultrasound identified an approximate 7-cm infrarenal AAA with a mural thrombus present. After receiving several computed tomography (CT) studies including CT head without contrast and CT angiography of the chest, abdomen and pelvis, the patient was diagnosed with acute thrombosis of AAA and associated thromboembolic occlusion of both his right and left distal iliac vessels causing bilateral acute limb ischemia. He immediately received unfractionated heparin and was admitted to the hospital for embolectomy and intra-arterial tissue plasminogen activator.

Discussion

Acute thrombosis of AAA and subsequent thromboembolic events are a rare but significant complication that can occur in patients with a history of AAA. Thromboembolic events may occur spontaneously or in the setting of blunt abdominal trauma. Common presenting signs and symptoms include distal limb ischemia and absent femoral pulses. Timely management and recognition of this rare complication is vital as this condition can ultimately result in limb loss or death if not treated in a timely manner. Heparinization after confirmation of non-ruptured AAA as well as vascular surgery, and therapeutic and vascular interventional radiology consultations are key steps that should be taken to decrease patient morbidity and mortality.

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.

An Unusual Case of Acute Thrombosis of Abdominal Aortic Aneurysm without Acute Limb Ischemia

Acute thrombosis of an abdominal aortic aneurysm (AAA) is a rare and often devastating complication with high morbidity and mortality. In some cases, however, it may be associated with a silent course without signs of acute limb ischemia. The aim of this report is to describe an unusual case of acute thrombosis of AAA without signs of acute limb ischemia. Preoperative anxiety, stress, and phobia for surgery may be factors predisposing to acute thrombosis of an AAA.

Endovascular Treatment of an Acutely Thrombosed Abdominal Aortic Aneurysm

BACKGROUND

Acute thrombosis of an infrarenal abdominal aortic aneurysm may be a life-threatening condition.

REPORT

We describe a case of acute thrombosis of a 3.5-cm abdominal aortic aneurysm resulting in threatened lower limbs, in a high-risk surgical patient. Emergency stent-graft placement was undertaken using Fluency endoprostheses. The patient remains well at 1-year follow-up.

CONCLUSION

High-risk surgical patients with acutely thrombosed abdominal aortic aneurysms may not be candidates for open surgery. Use of peripheral stent grafts in emergency situation has not been reported in such patients.

Incidental discovery of a chronically thrombosed abdominal aortic aneurysm: case report and literature review

Chronic spontaneously thrombosed abdominal aortic aneurysms (AAAs) are rare. We present a patient with a completely thrombosed abdominal aortic aneurysm found incidentally on imaging for evaluation of unrelated abdominal pain. The patient was asymptomatic with regards to the aneurysm due to extensive collateralization of the intercostal and lumbar arteries to the bilateral hypogastric and internal mammary arteries to the common femoral arteries bilaterally. Follow-up imaging after 10 months showed no aneurysmal change. Further study is needed regarding indications for elective repair, medical therapy, and surveillance modality and schedule for patients with chronically occluded AAAs as these patients are at risk for aneurysm rupture and thrombus propagation.

Chronic complete thrombosis of abdominal aortic aneurysm: An unusual presentation of an unusual complication

Although mural thrombosis frequently accompanies aneurysmal disease, complete thrombosis is distinctly unusual complication of abdominal aortic aneurysm (AAA). A case study of a patient with chronic, asymptomatic complete thrombosis of a large juxtarenal AAA is presented along with a literature review and discussion of the potential secondary complications, mandating aggressive management of this condition. A 67-year-old man with multiple atherogenic risk factors and unattended complaints consistent with a recent episode of a transient right hemispheric ischemic attack was referred to our clinic with a diagnosis of a thrombosed AAA established by computed tomography. Duplex ultrasonography and aortography confirmed the referral diagnosis and also revealed near occlusion of the left internal carotid artery. The patient underwent a two-stage surgery, with preliminary left-sided carotid endarterectomy followed three days later by an aneurysmectomy and aortobifemoral reconstruction. He had an uncomplicated recovery and was discharged home on postoperative day 7, remaining asymptomatic at the 42-month follow-up. Complete thrombosis is an uncommon presentation of AAA and may be clinically silent. It is frequently associated with other manifestations of generalized atherosclerosis. Radical open repair yields durable result and is the preferred treatment modality.