CASE REPORT Rupture of abdominal aortic aneurysm with pulmonary embolism and without an aortocaval fistula Gordana Čavrić1, Dubravka Bartolek2, Klara Jurić1, Mirjana Vukelić Marković3, Duško Kardum1 Dubrava University Hospital, Department of Internal Medicine, Division of Intensive Care, 2University Hospital of Traumatology, Department of Anaesthesiology, Reanimation and Intensive Care, 3Dubrava University Hospital, Division of Diagnostic and Interventional Radiology; Zagreb, Croatia 1 Corresponding author: Gordana Čavrić Dubrava University Hospital, Department of Internal Medicine, Division of Intensive Care, Av. Gojka Suska 6, 10 000 Zagreb, Croatia Tel.: +385 1 29 03 188; ABSTRACT In this report, we presented a case of a patient with a ruptured abdominal aortic aneurysm (AAA) accompanied by pulmonary embolism but without an aortocaval fistula, which has not been reported so far. Key words: aortic aneurysm, pulmonary embolism, vascular fistula E-mail: [email protected] Original submission: 17 September 2007; Revised submission: 23 November 2007; Accepted: 29 November 2007. Med glas 2008; 5(2):125-127 INTRODUCTION CASE REPORT Pulmonary embolism is one of rare complications related to rupture of an abdominal aortic aneurysm (AAA). All reported cases of an AAA rupture accompanied by pulmonary embolism had a verified aortocaval fistula (1, 2). The case of the ruptured AAA and concurrent pulmonary embolism without development of an aortocaval fistula has not been reported in the literature. Spontaneous aortocaval fistula is found in 1% of all operations for the AAA and as much as 4% of operations for ruptured AAAs (1). A 72-year-old Caucasian male with pronounced adiposity (the body weight 90 kg, height 175 cm, Body Mass Index, BMI = 29.4) was admitted to the Intensive Care Unit immediately after a sudden loss of consciousness during a slight walk, with suspected pulmonary embolism. The patient had a myocardial infarction a number of years previously. He had not been smoking since then. On admission the patient was conscious, with preserved motor function but less communicative (Glasgow Coma Scale =13) (3). He was 125 Medicinski Glasnik, Volume 5, Number 2, August 2008 dyspnoic, pale, with skin covered with perspiration, hypotensive (60/40 mmHg). The heart rate was 99/min. The patient spontaneously complained of chest pain and mild abdominal tenderness to palpation. The liver edge was palpable 3 cm below the right costal margin. Within ten minutes of admission respiratory arrest occurred and the patient was intubated and placed on mechanical ventilation. An immediate electrocardiogram (ECG) done on admission to hospital showed no abnormalities. The heart and chest radiogram revealed an enlarged heart with the left cardiac silhouette extending to the lateral thoracic wall, and a high position of the diaphragm. An echocardiogram showed dilatation of the left cardiac ventricle with a mild apical hypokinesis and asynchronic septal movement as well as greater reduction in systolic function. Dimension of the right ventricle in diastole was 3.0 cm. Because of tachycardia we could not measure pressure in the right ventricle, tricuspidal regurgitation and speed of systolic flow through pulmonal valve. Perfusion scintigraphy of the lungs demonstrated the upper left lobe perfusion defect. D-dimers were 15.6 μg /ml (normal values to 0.25 μg /ml). Considering the overall clinical presentation of the patient, a concomitant disease was suspected and further assessment was performed. Abdominal ultrasonography (US) and computerized tomography (CT) showed a ruptured infra-renal AAA of 7 cm in transverse diameter. The patient underwent an emergency laparotomy with resection of the aneurysm and termino-terminal reconstruction of the aorta using a prosthetic graft (Uni-Graft® K DV, with a diameter of 18 mm and a length of 15 cm, LOT 2-4043-8348, B/Braun, Aesculap, Tuttingen, Deutschland). Despite surgical intervention and medical intensive care, he died 36 hours after surgery under the clinical picture of a multiorgan failure. An autopsy was not performed. Aortic aneurysm is defined as a localized abnormal dilation of the aorta having a diameter at least 1.5 times more than that of the expected normal diameter. The best predictor factor for rupture of the AAA is the maximal aortic diameter and the rate of aneurysm expansion (4,5). The smaller aneurysm has slower progression of the probability of its rupture, i.e. five-year rupture rate for the AAAs of less than 4.0 cm in diameter is a 2% (4), the AAAs of 4.0 to 4.9 cm are associated with the five-year rupture rate 3 to 12% (4). If the AAA diameter is 5.0 to 5.9 cm, 6.0 to 6.9 cm and ≥ 7 cm, an estimated five-year rupture rate is 25%, 35% and 75%, respectively (4). The annual rupture rate in the UK Small Aneurysm Trial was 2.2% per year during the first 3 years of follow-up with an initial AAA diameter 3-6 cm and an average 4.4 cm (4). The major risk factors for AAA include male sex, a history of ever smoking (defined as 100 cigarettes in a person’s lifetime), and age 65 years or older (5). Other lesser risk factors include family history, coronary heart disease, claudication, hypercholesterolemia, hypertension, cerebrovascular disease, and increased height. Factors associated with decreased risk include female sex, diabetes mellitus, and black race (5, 6). The development of pulmonary embolism is also one of rare complications related to the AAA rupture. There have only been cases of pulmonary embolism associated with spontaneous aortocaval fistula described in the literature so far (2). An aortocaval fistula is found in 1% of operations done for the AAA and 4% of operations for ruptured aneurysms (1). The concurrent occurrence of pulmonary embolism and the AAA rupture, but with no aortocaval fistula which has not been reported yet. The development of pulmonary embolism in this case may be due to pressure by the dilated aorta to the inferior caval vein with the resulting formation of thrombi and embolism at the moment of the AAA rupture. 126 Case report REFERENCES 1. Rajmohan B. Spontaneous aortocaval fistula. J Postgrad Med 2002; 48: 203- 5. 2. Lay JP, Swainson CJ, Sukumar SA. Paradoxical pulmonary embolism secondary to aortocaval fistula: diagnosis by helical CT. Br J Radiol 1999; 72:507- 9. 3. Teasdale G, Jennett B. Assessment of coma and impaired counsciousnes. A practical scale. Lancet 1974; 2(7872): 81-4. 5. U. S. Preventive Service Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med 2005; 142:198-202. 6. Lederle FA, Johnson GR, Wilson SE, Chute EP, Littooy FN, Bandyk D, Krupski WC, Barone GW, Acher CW, Ballard DJ. Prevalence and associations of abdominal aortic aneurysm detected through screening. Ann Intern Med 1997; 126: 441- 9. 4. Tan WA, Makaroun MS. Abdominal aortic aneurysm, rupture. [http://www.emedicine.com/radio/ topic2.htm] 127