| Could hybrid treatments be an option for abdominal aortic pseudoaneurysms? | |
| DOI: 10.5606/e-cvsi.2024.1730 | |
| Erturk Karaagac, Hasan Iner, Hidayet Onur Selcuk, Muhammed Cagri Yalcin, Levent Yilik | |
| Department of Cardiovascular Surgery, İzmir Katip Çelebi University Faculty of Medicine, İzmir, Türkiye | |
| Keywords: Aortic pseudoaneurysm, debranching, endovascular, hybrid treatment, traumatic injury | |
Traumatic pseudoaneurysm of the abdominal aorta is a life-threatening and rare pathology that often occurs after blunt trauma or
penetrating injuries. In suprarenal pseudoaneurysms, surgery is complicated by the classic approach, as access to the abdominal aorta is
difficult due to the complex anatomy, with a high risk of bleeding. Therefore, hybrid solutions should always be considered in areas with
a high risk of spontaneous rupture. In this case report, we presented a successful hybrid surgical option with endovascular aortic stent
grafting and visceral debranching in a 20-year-old male patient with an abdominal aortic pseudoaneurysm. |
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Traumatic pseudoaneurysm of the abdominal
aorta is a life-threatening and rare pathology that
often occurs after trauma.[1] After trauma, the clinical
presentation may be asymptomatic, or symptoms may
occur due to compression. However, the most feared
situation is spontaneous rupture leading to death.
Therefore, it should be treated quickly and with the
most appropriate approach. The part of the abdominal aorta where the pseudoaneurysm is located is extremely important for the surgical approach. In suprarenal pseudoaneurysms, the classic approach makes operation more difficult, as access to the abdominal aorta is difficult due to the complex anatomy, with a high risk of bleeding. Therefore, hybrid solutions should always be considered for suprarenal abdominal aortic pseudoaneurysms, where the risk of spontaneous rupture is high.[2] In this case report, we presented a successful hybrid operation in a patient who was diagnosed with a traumatic abdominal aortic pseudoaneurysm after complaining of abdominal pain on the postoperative Day 14. |
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CASE PRESANTATION
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A 20-year-old male patient underwent urgent
surgery by a general surgeon for hemodynamic
instability following a gunshot wound to the abdomen. After laparotomy, the retroperitoneum
was examined, and although there was a small
amount of retroperitoneal bleeding, the vascular
structures were found to be intact. The patient,
who had been complaining of abdominal pain
since postoperative Day 14, underwent computed
tomography angiography (CTA). The CTA showed
a 77x51x64 mm pseudoaneurysm originating from
the abdominal aorta at the level of the celiac trunk
(CT) and located in the left lateral retroperitoneum
(Figure 1a, b). A written informed consent was
obtained from the patient for pseudoaneurysm repair,
and the patient was taken for reoperation. Under
general anesthesia, the visceral arteries and the right
common iliac artery were explored and released. A
bypass to relieve the abdominal aorta was created
from the right common iliac artery to the CT
with an 8-mm Dacron graft. A bypass was then
created from the CT graft to the superior mesenteric
artery using an 8 mm Dacron graft. After the visceral debranching procedure, the CT and superior
mesenteric artery were ligated. A 20¥20¥82 mm
endovascular aortic stent graft was then placed in
the suprarenal region to contain the pseudoaneurysm
sac. A control angiography was performed (Figure 2).
After hemostasis, the operation was completed. The patient was transferred to the ward two days later.
The patient's control CTA (Figure 3a, b) revealed
that the pseudoaneurysm sac was thrombosed, and
the debranching grafts were patent. The patient was
discharged on postoperative Day 10. The patient’s
follow-up treatment has been continued routinely. |
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Penetrating abdominal aortic injuries still have
a high mortality rate despite the rapid intervention
of the trauma team. This type of injury may be
associated with rupture and massive hemorrhage
leading to death, and it is also known to be limited
to the development of a pseudoaneurysm due to
the retroperitoneal location of the abdominal aorta.
Although aortic injury is not clearly recognizable on
initial exploration, the presence of retroperitoneal
hemorrhage at the time of exploration should raise
suspicion. In such cases, it is possible to detect severe
and potential pathologies, such as pseudoaneurysm,
with CTA during follow-up.[3] In a pseudoaneurysm that develops due to penetrating abdominal aortic injury, a variety of clinical findings, such as abdominal pain, pulsatile hematoma in the abdomen, bile duct obstruction, and ileus, can be observed.[4] These clinical findings are exacerbated depending on the size of the pseudoaneurysm sac. The time interval between the initial trauma and the onset of clinical symptoms can vary from a few days to years. Although it is difficult to make a diagnosis in the late phase, particularly if there is a suspicion in the early phase, patients should be examined with modern imaging techniques without wasting time. In the initial examination, CTA is preferred due to its high sensitivity in making a diagnosis. Computed tomography angiography not only provides information on the location and size of the lesion but also serves as a guide for surgical planning. Graft interposition can be performed during open surgical repair of a pseudoaneurysm.[5] In suitable patients, repair with endovascular stent grafts or coil embolization should always be considered. However, hybrid procedures with endovascular aortic stent grafting and debranching may be a solution in cases where open surgery presents high risk due to the location of the pseudoaneurysm and where endovascular treatment alone is not suitable due to the visceral arterial structures. Open surgical repair of pseudoaneurysms adjacent to visceral arterial structures is associated with a high mortality rate due to the difficulty in controlling the aorta and the risk of massive bleeding. Therefore, the use of various treatment procedures in high-risk cases has come to the fore with the developments in endovascular surgery. In a case series published by Scali et al.,[6] it was found that fenestrated endovascular treatment can also be used in pseudoaneurysm repair. Although pseudoaneurysm treatment is possible with this method, the technical difficulties, the risk of branched stent thrombosis, and the endoleak risk should not be disregarded. Hybrid treatments offer us an alternative to minimize these risks.[2] In the hybrid treatment, which we preferred in this case, visceral debranching is first performed on the common iliac arteries, which represent a safe area. Afterward, the bypassed arteries are ligated from the aorta, and the hybrid procedure is rapidly completed by inserting the endovascular aortic stent graft. In this way, pseudoaneurysm repair is performed with less risk than open surgical repair, and patency of the visceral arterial structures is guaranteed. In conclusion, pseudoaneurysms that develop due to penetrating abdominal aortic injury are a life-threatening pathology that can lead to death even before symptoms appear. In case of doubt, the diagnosis should be made using modern imaging techniques, and the optimal treatment protocol tailored to the patient should be determined. It should be kept in mind that hybrid treatment with endovascular aortic stenting and debranching may be the solution in high-risk cases. Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request. Author Contributions: Conception or design of the experiment(s), or collection and analysis or interpretation of data: E.K., H.I. Drafting the manuscript or revising its intellectual content: E.K., H.I., O.S., M.C.Y.; Approval of the final version of the manuscript to be published: L.Y. Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article. Funding: The authors received no financial support for the research and/or authorship of this article. |
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