Case Presentation:
The patient was a seventy-year-old man who went to the emergency department with complaint of acute abdominal pain, nausea, vomiting, and oral intake intolerance during the last 4 days.
The patient had abdominal pain with preference of epigastric region radiated to back in the past 4 days before admission which became intensively severe over the last few hours. In both inspection and palpation, significant findings which stood out were a protuberant abdomen with expansile pulsation.
He stated that over the last year he felt a periumbilical mass and pulsation, however, he did not go to a doctor and follow up.
In his medical history, he had been smoking for 50 years, 1 pack daily, and no diabetic mellitus, hypertension, ischemic heart disease, and dyslipidemia were reported. At the time of admission, vital signs including respiratory rate = 17 per minute, pulse rate = 112 per minute, blood pressure right hand 98/48 mm Hg and left hand 99/46 mm Hg, O2 saturation = 95%, and temperature = 36.6°C. In superficial palpation, it was observed that the abdomenprotruded and the patient had tenderness in the epigastric region and did not allow deep touching. No bowel sound was osculated in 4 quadrants of the abdomen in one minute.
Laboratory tests of the patient from initial blood sample showed: WBC = 14.4 (103/µL) (normal range 4‐10), Hb = 11.3 (g/dL) (normal range 14‐18), Platelet = 136 (103/mm3) (normal range 140‐440), PT = 18.2 seconds, PTT = 36 seconds, and INR = 1.46, BUN=29.1 mg/dl, Cr=2.20, Na=149, K=4.1 mg/dl, AST=117, ALT=110, Bilirubin total=1.8 and direct=0.5
In the emergency abdominopelvic sonography, which conducted for the patient in the emergency room, evidence of a thoracoabdominal aortic aneurysm was observed. The patient with systolic blood pressure of 70 mm Hg underwent spiral thoracoabdominal CT scan with IV contrast. In tomography report, a giant aneurysmal dilation of the aorta from diaphragm aortic hiatus continued downward to infrarenal aorta with diameter of 103×148 mm and approximate length of 164 mm containing a huge mural thrombus. Additionally, evidence of contrast leak from aneurismal sac was noted. Moreover, a huge hematoma in the right retroperitoneal space pushing the right kidney forward and compressing the bowel and the collapse of the stomach were reported. (Figure1)
Laboratory tests of the patient from second blood sample showed Hb=2.6 which demonstrated an acute bleeding due to the rupture of aneurysm sac. The patient was resuscitated with 4 units of packed red blood cells and fresh frozen plasma and transferred to the emergency operation room. He underwent induction for general anesthesia with ketamine and maintenance with fentanyl, atracurium, and midazolam. The patient blood pressure was under control between 70-80 mm Hg with nepride and vasopressin.
Midline incision was performed and proximal aortic control achieved at diaphragmatic hiatus. The Aneurysm sac was incised, and the huge hematoma was removed and sent to the pathology.(Figure2) And aorto-renal reconstruction surgery was performed on the patient. (Figure3) After uneventful recovery, he was transferred to intensive unit care with norepinephrine drip. Finally, the patient completed an uneventful post-operation course.