Successful use of emergent endovascular aneurysm repair for a ruptured hypotensive abdominal aortic aneurysm

Abstract

CASE REPORTA 66-year-old man presented to an emergency department with acute abdominal pain. The pain started abruptly and was severe in nature starting several hours before. Just prior to ED arrival, the patient had a brief syncopal episode lasting 1 -2 minutes. He complained of nausea but denied difficulty breathing, chest pain or recent illness. He had a past medical history significant for a myocardial infarction, hypercholesterolemia and hypertension. He denied smoking. His initial vital signs were temperature, 36.4˚C; heart rate, 101 beats per minute; respiratory rate, 18 per minute; and blood pressure, 97/56 mmHg. On physical examination, he appeared pale and in distress. His chest and cardiac examination were unremarkable. His abdomen was protuberant with marked diffuse tenderness and a pulsatile abdominal mass. A bedside ultrasound was immediately obtained that demonstrated a large AAA. Initial laboratory tests revealed a white blood cell count of 19.08 H/nL, hemoglobin of 13.3 g/dL, a creatinine of 1.3 mg/dL, and a troponin-I of 0.099 ng/mL. The remainder of the initial laboratory tests was unremarkable. Shortly after ED arrival the patient's systolic blood pressure decreased to 60 mmHg. With intravenous fluids the systolic blood pressure rose into the 70 -80 mmHg range. The patient remained awake and oriented with these blood pressures.The initial diagnosis was a hemodynamically unstable ruptured abdominal aortic aneurysm in need of acute surgical repair with a high mortality risk. The patient was considered for endovascular aneurysm repair and underwent an emergency CT scan of the abdomen and pelvis to assess eligibility for this procedure. Despite having a blood pressure that was in the 70 -80 mmHg range, the patient remained awake and alert. The patient was accompanied by the vascular surgery team to radiology while the CT scan was performed. The pre-radiology plan was if the patient decompensated during the performance of the CT scan, the vascular team would discontinue the CT scan and immediately take the patient for emergency open operative repair of the AAA.