Case presentation
Patient of 63 years old, who came to consult for abdominal pain of gravity type evolving for about 3 months, occurring during a lifting of a bucket of water, followed by orthostatic palpitations of sudden onset, of great intensity and a loss of consciousness with sudden remission, the evolution will be marked by loss of consciousness on 3 occasions, and pain with sensation of a pulsating mass in the left flank, which would have motivated the consultation at the General Hospital of Reference Dr. Rau Ciriri where a diagnosis of abdominal aortic aneurysm was made and a transfer to the General Hospital of Reference of Fomulac was decided for better management
She did not recognize herself as hypertensive, neither diabetic nor cardiopathic, did not take alcohol, G9P7A2Ev7, postmenopausal for more than 10 years and was not on any particular anticoagulant treatment with no fever, no headache.
On physical examination: general condition preserved and vital signs were within norms: blood pressure: 130/70mmHg, heart rate: 98bpm, respiratory rate: 22cpm, temperature: 36.1 Celsius degree and anthropometric parameters: Weight: 110kgs, Height: 1.72m BMI: 37.9kgs/m2
Colored palpebral conjunctiva, an icteric bulbar conjunctiva, clean mouth, moist tongue, free cervical and head ganglion areas, supple neck, and no turgid jugular veins. Thorax: symmetrical, eupneic, clear lungs.
Cardiovascular examination reveals regular heart, slightly tachycardia, first and second sounds audible without pathological noises, warm extremities, and capillary recoloration time inferior to 3 seconds, peripheral pulses palpated and synchronous.
The abdomen was following the respiratory movements, there is a large adipose pannicle, liver and spleen not palpated, presence of a more or less firm mass, linear at the level of the left flank, pulsatile and synchronous with the heartbeat, continuing with the spleen, peristalsis present
We concluded to: pulsatile mass of the abdomen: Abdomino-thoracic aneurysm or Angioma and a metabolic syndrome: Arterial hypertension and Obesity
Para clinical examination:
Hemoglobin: 13.2g/dl Clotting time: 4’30” Bleeding time: 1’30 ”Blood type: O rhesus + Serology: HIV: negative, HBS: negative and HCV: negative Blood glucose: 127 mg/dl
Angio-scan reveals an aneurysmal dilatation of the abdominal aorta (Figure 1). This dilatation begins just after the emergence of the renal arteries and extends upstream of the bifurcation of the primitive iliac. Its major axes 70 x 69 mm (LL x AP). Its height is 129 mm. Its posterior wall presents a thrombus of 34 X 20 mm X 51 mm (LL X AP X CC). The supra renal aorta has a tortuous course; its diameters are 22 X 23 mm (AP X LL). Liver size and contours within the norms. Small hypo intensive and non-enhancing lesion of 7 mm in segment VII: Biliary cyst a priori. No dilatation of the intra- or extra-hepatic bile ducts. Normotensive gallbladder with homogeneous content. Homogeneous enhancement of the pancreas. Thin adrenal glands. Kidneys of normal size and topography, with symmetrical parenchyma. No hydronephrosis. Bladder not very full, with thin wall and homogeneous content. Normal arrangement and size of the digestive tracts. Homogeneous enhancement of their walls. Multiple calcifications of the pelvis: probable phleboliths. No ascites or adenomegaly along the major vascular axes. No suspicious nodule at the pulmonary bases or pleural effusion. No suspicious bone lesions. Degenerative remodeling (lumbar spondylosis) multistage predominantly in L5-SI or they are responsible for a grade I anterolisthesis. Also, moderate bilateral sacroiliac osteoarthritis.
Conclusion: A saccular aneurysm of the infra-renal abdominal aorta with a posterior intramural thrombus is retained.
We managed the patient by performing an open sky surgical repair which steps were these one hereafter: the patient was installed in dorsal decubitus position under general anesthesia, extensive disinfection of the surgical site and sterile drape. Vertical incision above and below the umbilicus, dislocation of the duodeno-jejunal angle: progressive aneurysm at the right and superior mesenteric border up to the level of the inferior border of the left renal artery, sub-renal aorta well visualized and ready to be dissected. Opening of the sigmoid peritoneum up to the bifurcation of the primitive iliacs. Continuation of dissection exposing the primitive iliacs while sparing the right ureter. Subrenal clamping of the aorta and two primitive iliacs. Opening of the aneurysm, blood aspiration, removal of thombii as you can see on figure 2.
Hemostasis control of thrombosed vertebral and middle sacral arteries, inferior mesenteric arteries. Control of hemostasis with 4/0 prolene, placement of the 14mm prosthesis and proximal suture with 2 hemi-overlays with 5/0 prolene, distal suture with 2 hemi-overlays with 5/0 prolene as you can see on figure 3. Perfect control of hemostasis. Clamping: the suture is tight. Closure of the aneurysmal wall covering the prosthesis, closure plane by plane and betadine dressing as you can see on figure 2. We got immediate postoperative awakening and postoperative monitoring did not notice any particularity. We kept her in the hospital under ciprofloxacin 2 times 400mg per day, Metronidazole 3 times 500mg per day,, Enoxaparin 2 times 0.8mL per day, and paracetamol 2times 1grams per day,, Tramadol 3 times 100mg per day, and Diclofenac 2times 75mg per day,. We discharged her 12 days post-surgery under low-dose aspirin 100mg per day. We saw her 3 months and 6 months after discharge and all parameters were normal.