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.