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.