A 79-year-old woman with atrial fibrillation, hypertension and hypothyroidism presented to the emergency department with syncope. She had previously experienced three minor syncopal episodes. A few months earlier, she had been prescribed rivaroxaban 15 mg/d after many years of warfarin therapy. On the day of presentation, she had woken feeling weak and fell to the floor, but managed to call 911. Following the initial assessment by emergency medical services she became unresponsive and briefly pulseless, and cardiopulmonary resuscitation was performed.In the emergency department, the patient was resuscitated with several boluses of normal saline, one unit each of packed red blood cells, platelets and prothrombin complex concentrate. Her vital signs stabilized. Diffuse abdominal guarding and tenderness were noted on examination. No prior intra-abdominal surgery was reported, and there was no definite antecedent infection.The patient's leukocyte count was 19.9 (normal 4.0-10.5) × 10 9 /L, plasma lactate level 12.4 (normal 0.5-2.2) mmol/L and hemoglobin 83 (normal 120-160) g/L; her hemoglobin level had been 121 g/L two months earlier. The international normalized ratio was 4.2 (normal 0.9-1.1). The platelet count and lipase level were within normal limits.Contrast-enhanced computed tomography (CT) showed a large intraperitoneal hematoma centred on a 3-cm pseudoaneurysm in the expected location of the pancreaticoduodenal arteries ( Figure 1). There were several smaller fusiform aneurysms arising from the celiac and superior mesenteric branch vessels. In the descending thoracic and abdominal aorta, there was an intramural hematoma, with active filling of multiple penetrating ulcerations ( Figure 2).Interventional radiology was consulted for angiography and potential transcatheter embolization. Angiography confirmed the CT findings, including a 3-cm pseudoaneurysm arising from the inferior pancreaticoduodenal artery. The artery was selected with a Progreat microcatheter (Terumo Interventional Systems), and the segments of the artery proximal and distal to the 3-cm ruptured pseudoaneurysm were embolized with five Nester embolization coils 3 mm × 14 cm (Cook Medical) and two Interlock embolization coils 3 mm × 12 cm (Boston Scientific) ( Figure 3).Angiography of the celiac and superior mesenteric arteries showed many smaller aneurysms involving several branch vessels. Given that these aneurysms were not easily accessible and did not meet the size criteria of 2 cm, they were not embolized. The interventional radiologist suspected vasculitis as the underlying cause. The smaller aneurysms were therefore expected to respond to medical therapy and did not require immediate intervention.Following endovascular coiling, investigations showed an increase in nonspecific inflammatory markers, including a C-reactive protein level of 180.1 (normal 0-1.0) mg/L and an erythrocyte sedimentation rate of 60 (normal 0-27) mm/h. Results of serologic evaluations were within normal limits, including tests for antineutrophil antibodies, anti-ex...

No abstract

Supplemental Digital Content is available in the text.