Introduction pseudoaneurysm which was morphologically in- distinguishable from a true aneurysm. Infra-renal con-. The majority of pseudoaneurysms post ...
EJVES Extra 1, 63–64 (2001) doi:10.1053/ejvx.2001.0034, available online at http://www.idealibrary.com on
CASE REPORT
Aortic Pseudoaneurysm Posing as a True Aneurysm R. Chana∗1, J. Abrokwah2, M. Siddiqui2, P. Burns2 and A. Mahomed2 1
Vascular Unit, Department of Surgery, Lister Hospital, Corey’s Mill Lane, Stevenage SG1 4AB, U.K.; 2 Lister Hospital, Stevenage, U.K.
Introduction The majority of pseudoaneurysms post abdominal aortic aneurysm (AAA) repair, occur in the groin with aortic pseudoaneurysms being less frequently encountered.1,2 We report an unusual case of an aortic pseudoaneurysm, in which the old aneurysm sac reformed the pseudoaneurysm wall.
Case Report A 91-year-old male patient was admitted with a 2week history of back-ache. Fifteen years previously he had undergone an emergency aortic aneurysm repair for a ruptured aortic aneurysm. Despite his age he lived independently and had no significant cardiac or cerebrovascular history. He was an ex-smoker, with no other risk factors for atherosclerosis. The patient was in slow atrial fibrillation but had a normal pulse rate and blood pressure. Abdominal examination revealed a large non-tender abdominal aortic aneurysm. An urgent CT scan demonstrated a 10 cm infra-renal abdominal aortic aneurysm with radiological features consistent with a true aneurysm. The option and urgency of surgery was discussed with the patient but he initially refused intervention. Two days later he agreed to surgery, but as the appropriate arrangements were being made he became acutely unstable and had to undergo an urgent laparotomy. At laparotomy he had an anterior rupture of the ∗ Correspondence to: R. Chana, Flat 5, Barrymore, Bow Lane, Finchley, London N12, U.K. 1533–3167/01/000000+00 $35.00/0 2001 Harcourt Publishers Ltd.
pseudoaneurysm which was morphologically indistinguishable from a true aneurysm. Infra-renal control of the aorta and both common iliac was achieved. On opening the pseudoaneurysm wall, the straight, Dacron graft was found collapsed on the posterior wall with both ends of the end to end anastomosis disrupted anteriorly. The pseudoaneurysm was repaired with a tube Dacron graft anastomosed to the aorta proximally and the origins of the common iliac arteries distally Post surgery, the patient had a few cardiac problems and was discharged home under self-care 3 weeks after the procedure.
Discussion Complications following AAA repair include graft thrombosis, infection, aorto-enteric fistulas and anastomotic aneurysms. True pseudoaneurysm formation following AAA repair has a reported incidence of between 0.2% and 15%.2–4 Most aortic pseudoaneurysms occur late (average 8–10 years) after aortic grafting. Once pseudoaneurysms are detected, they appear to increase in size and many give rise to complications. Some authors have reported rupture at presentation in thirty to over forty percent of patients.3 Outcome following emergency repair is uniformly poor with excellent results reported for elective surgery.1 Thus, elective surgical repair is recommended when the diagnosis of aortic pseudoaneurysm is made. The case for or against routine surveillance following aortic grafting is still unclear, as there is not enough follow up data to make informed recommendations. Those who recommend routine surveillance perform
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the first ultrasound examination at 5 years with scans at 2-yearly intervals thereafter.5 The case we report is unusual as it appeared radiologically and morphologically to be a true aneurysm. The presumed course of events would be the development of pseudoaneurysms at either anastomosis with the intervening tissue subsequently disrupting, thereby forming a single lumen. The blood flowed from the infrarenal aorta to the distal aortic cuff, bypassing the graft.
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References 1 Curl RG, Faggioli GL, Stella A, D’Addato M, Ricotta JJ. Aneurysmal change at or above the proximal anastomosis after infrarenal aortic grafting. J Vasc Surg 1992; 16: 855–860. 2 Ryan T, Hagino MD, Spence M, Taylor MD, Roy M, Fujitani MD, Mills JD. Proximal anastomotic failure following infrarenal aortic reconstruction: late development of true aneurysms, pseudo-aneurysms and occlusive disease. Ann Vasc Surg 1993; 7: 8–13. 3 Plate G, Hollier LA, O’Brien P et al. Recurrent aneurysms and late vascular complications following aortic aneurysms. Arch Surg 1985; 120: 590–594. 4 Edwards JM, Teefey SA, Zierler RE et al. Intra-abdominal paraanastomotic aneurysms after aortic bypass grafting. J Vasc Surg 1992; 15: 344–353. 5 Allen RC, Schneider J, Longenecker L, Smith RB et al. Paraanastomotic aneurysms of the abdominal aorta. J Vasc Surg 1993; 18: 424–432.
