Unilateral Lower Limb Paralysis After Aortobifemoral Bypass Graft for Ruptured Abdominal Aortic Aneurysm: A Case Report

Abstract

An 81-year-old man underwent an aortobifemoral bypass graft because of a ruptured abdominal aortic aneurysm. His postoperative recovery was complicated by unilateral lower limb paralysis caused by perioperative ischemia of the lumbosacral plexus. Ischemic lumbosacral plexopathy is an uncommon complication after infrarenal aortic surgery with serious morbidity.Despite a good surgical technique and knowledge of the vascularization of the spinal cord, its occurrence remains unpredictable.An 81-year-old man was urgently referred to the emergency services by his treating physician because of acute abdominal pain, mainly in the left flank. On admission, he was pale and suffered from hypotension (blood pressure 50/30 mm Hg). A computerized tomography (CT) was performed, which showed a ruptured juxtarenal abdominal aortic aneurysm. The patient was rushed to the operating room, where an aortobifemoral bypass was performed. There was a suprarenal clamp time of 25 minutes. As nefroprotection rescuvolin (folic acid) and lysomucil (acetylcysteine) were given. There were no important periods of hypotension perioperatively, despite the need for massive transfusion (2 L of autotransfusion, 8 units of packed cells, 4 units of fresh frozen plasma, and 2 pools of thrombocytes, perioperatively). The patient was extubated the same day. The next morning, he complained of hypoesthesia and paresis of his right leg. We also noticed rising of his serum creatinine and urea levels and a potassium level of 6.5 mmol/L (3.5-5.1 mmol/L). Glucose and insulin were started to correct the potassium level, and a subclavian dialysis catheter was used for dialysis. After a few days, potassium, creatinine, and urea levels normalized and all therapies were stopped, but the paralysis and paresthesia of the right limb remained. A CT scan of the brain ruled out any central etiology and an electromyogram (EMG) confirmed peripheral pathology (combined drop foot and plantar flexion paralysis) and our diagnosis of ischemic lumbar plexopathy. Magnetic resonance imaging (MRI) of the lumbar spine 3 weeks postoperative was negative. When the patient was discharged, limited mobilization was possible with aid. DiscussionLower limb paralysis following aortoiliac procedures is a known but rare complication. The overall neurologic risk of endovascular and open infrarenal abdominal aortic surgery ranges between 0% and 1%. 1 The risk is higher for emergency cases (1.4-2%) than for elective cases 2 (0.1-0.2%) and consists of central cord, lumbosacral, and peripheral nerve From the Department of Vascular and Thoracic Surgery, AZ Groeninge Kortrijk, Belgium.

Transient Unilateral Lower Limb Palsy after Open Surgery Thoraco-Abdominal Aorta Repair

“…It is a rare complication after aorto-iliac surgery: The diagnosis was ischemic lumbar plexopathy (Magnetic Resonance Imaging of the spine was negative 3 weeks later). The patient showed a partial deficit when discharged [9].…”

Ketamina para analgesia de la plexopatía lumbosacra secundaria a la reparación de un aneurisma de aorta abdominal

“…Al examen físico se encuentra paraparesia asimétrica, disminución de los reflejos osteotendinosos, disestesias o parestesias en la distribución de las raíces lumbosacras (5). Estas lesiones, por lo general, cursan con un pronóstico clínico favorable a pesar de que su recuperación sea difícil de predecir (6,7). Las ayudas diagnósticas como la resonancia magnética y los estudios neurofisiológicos son poco específicos y de baja utilidad; por tal motivo, es importante un examen neurológico completo (8,9).…”

“…La irrigación se deriva de la arteria circunfleja iliaca profunda y de las arterias iliolumbar, glútea superior e inferior y sacra lateral, las cuales son ramas de la arteria iliaca interna (7,10,11). En primer lugar, el plexo lumbar esta irrigado principalmente por arterias lumbares gracias a su ubicación en el musculo psoas, sin embargo existen varias arterias colaterales derivadas en su mayoría de ramas de la iliaca interna que protegen en caso de oclusión masiva de las arterias lumbares, y en segundo lugar, la principal fuente sanguínea del plexo sacro deriva directamente de la arteria iliaca interna (6-8).…”