Case Reports Posttraumatic Infrarenal Abdominal Aortic Pseudoaneurysm

Raoul Bononi, MD Posttraumatic abdominal aortic pseudoaneurysm is a rare lesion. To date, fewer than 30 Manano Garofalo, MD cases have been reported in the literature, with most of those cases involving the supra- Francesco Seddio, MD Luisa Colagrande, MD renal aorta. Infrarenal posttraumatic abdominal aortic pseudoaneurysm following ab- Bonaventura Manno, MD dominal trauma has been reported in only 6 other cases. We observed such a lesion in a Paolo Albano, MD 62-year-old man 15 years after blunt abdominal trauma inflicted in a car accident. Back pain was the presenting symptom. Resection and Dacron® graft interposition were per- formed without postoperative morbidity. (Tex Inst J 1999;26:312-4)

Psosttraumatic abdominal aortic pseudoaneurysm (PAAP) may occur as a consequence of blunt or '2 and may present many years after the initial injury.3 The following reports a case of infrarenal PAAP observed 15 years after a car accident. Case Report

In October 1996, a 62-year-old man was referred for further evaluation of a small abdominal aortic , which had been diagnosed a few days earlier by means of abdominal ultrasonography performed in order to determine the nature of his back pain. He had a history of blunt abdominal trauma sustained in a car accident 15 years prior. On physical examination, a vascular bruit was present in the umbili- cal region, but no pulsatile mass was palpable. A contrast-enhanced computed tomogram ofthe abdomen demonstrated a 4-cm saccular aneurysm arising from the right side of the infrarenal abdominal aorta (Fig. 1). An aortogram confirmed this Key words: abdominal injuries/complications; finding (Fig. 2). aneurysm, false/etiology; Elective repair of the abdominal aneurysm was performed through a midline aneurysm, false/surgery; incision. The aneurysm was in the middle third of the infrarenal abdominal aorta. , abdominal; wounds, nonpenetrating/ The aorta and iliac were of normal diameter and were free of any athero- complications sclerotic involvement. Endoaneurysmectomy with interposition of a Dacron® tu- bular graft was performed. The patient had an uneventful postoperative course, From: The Department of and he was discharged 7 days later. , European Histologic examination of the aneurysm's wall showed that the adventitia was Hospital (Drs. Borioni and covered by fibrotic tissue, which confirmed the direct diagnosis of false aneurysm Garofalo); the Division of Cardiac Surgery, University (Fig. 3). of Rome Tor Vergata, (Drs. Seddio and Discussion Colagrande); and the Department of Pathology (Dr. Marino) and Service of Posttraumatic abdominal aortic pseudoaneurysms are rare. Most PAAPs are caused Angiology (Dr. Albano), by penetrating injury of the upper abdomen, such as a gunshot or knife wound. Aurelia Hospital, Rome, Italy Posttraumatic abdominal aortic pseudoaneurysms caused by blunt trauma are usu- ally in the thoracic aorta,45 but they may also occur in the abdominal tract. Our Address for reprnts: review of the literature revealed 27 cases of PAAP, most of which (79%) were Raoul Borioni, MD, European Hospital, caused by penetrating injury.3'6'7 Posttraumatic abdominal aortic pseudoaneurysms Via Portuense, 700, of the infrarenal tract are quite rare, accounting for only 6 other cases described in Rome, 00149, Italy the literature; to our knowledge, our patient is the oldest whose case has been reported to date. Two-thirds of these cases were related to blunt abdominal trau- 1999 by the Texas Hearte ma.3 Does and Brouwer8 report a single case of false aneurysm of the abdominal Institute, Houston aorta without previous trauma.

312 Posttraumatic Infrarenal Abdominal Aortic Pseudoaneurysm Volume 26, Number 4, 1999 .., t

fI. - -\...

Fig. 1 Abdominal computed tomogram displays the aneurysm (arrows) of the infrarenal aorta.

Ao = aorta; PA = pseudoaneurysm

Fig. 3 Fibrotic tissue (ft) covering the adventitia (adv).

undergone exploratory laparatomy 32 years before, after a gunshot wound to the abdomen. The present report describes an uncommon infra- renal PAAP following blunt abdominal trauma and confirms that such traumatic sequelae can become symptomatic many years after initial injury. In addi- tion to instrumental evaluation (such as ultrasonog- raphy, contrast-enhanced computed tomographic scan, and spiral computed tomographic scan) during Fig. 2 Abdominal aortogram shows the aneurysm (arrows). the acute phase following major abdominal trauma, we suggest long-term follow-up with ultrasono- graphic assessment of the abdominal aorta, even if Clinical presentation of PAAP may be dramatic. there is no evidence of early retroperitoneal aortic Spontaneous rupture induces hypovolemic shock and lesion. This approach is justified by the high mortal- carries a mortality rate that approaches 100%. The ity rate associated with spontaneous rupture and the symptoms of unruptured PAAPs are variable, usually good results of surgical treatment and endoluminal consisting ofabdominal or back pain, or signs ofcom- repair with a -graft. pression on surrounding structures, such as the biliary Currently, major abdominal surgery in selected tract, vena cava, and renal arteries. Upper gastroin- patients can be avoided with the percutaneous place- testinal bleeding, thromboembolic phenomena, and ment of endoluminal stent-grafts. This is important sepsis have also been reported. The time interval from in patients with an abdominal aortic aneurysm be- initial injury to symptomatic display has ranged from cause of the high incidence of coexisting morbid 4 days to 32 years. This variance suggests that abdom- conditions9 that increases the morbidity and mor- inal aortic trauma should be considered as a possible tality rates in surgery cases. cause at the time of the patient's presentation, even if In 1991, Parodi and associates10 1st described the exploratory laparotomy was performed at the time of use of a nonbifurcated stent-graft in patients with the initial injury. Recently, Chase and coworkers3 infrarenal aortic aneurysm. Subsequently, Parodi reported a case of biliary obstruction secondary to a strongly suggested the use of a stent-graft for treat- 6-cm aortic pseudoaneurysm in a patient who had ing vascular trauma, including false and

Texas Heart Institutejournal Posttraumatic Infrarenal Abdominal Aortic Pseudoaneurysm 313 arteriovenous fistulae.1I In fact, all trauma cases so 13. Blum U, Voshage G, Lammer J, Beyersdorf F, Tollner D, Kretschmer G, et al. Endoluminal stent-grafts for infra- treated by Parodi were successful over the short and renal abdominal aortic aneurysms. N Engl J Med 1997; long terms. White and colleaguesl2 confirmed this 336:13-20. result by demonstrating, after 3 months of follow- up, the exclusion of the pseudoaneurysm in a gun- shot injury to the visceral aorta treated with a stent-graft. Recently, Blum and coworkersl3 studied the use of stent-graft endoprostheses-made of niti- nol and covered with polyester fabric-for the treat- ment of true infrarenal abdominal aortic aneurysm. They concluded that endovascular treatment of infrarenal aortic aneurysm is feasible and safe but needs further refinement. Our patient was certainly suitable for either surgical or endovascular treat- ment. We chose the conventional technique of sur- gical repair of the PAAP because we had begun our program of endoluminal grafting only a few months before. With improvements in our experience and technique, we will in future consider such patients for the less invasive alternative. References 1. Potts RG, Alguire PC. Pseudoaneurysm of the abdominal aorta: a case report and review of the literature. Am J Med Sci 1991;301:265-8. 2. Pisters PW, Heslin MJ, Riles TS. Abdominal aortic pseudo- aneurysm after blunt trauma. J Vasc Surg 1993;18:307-9. 3. Chase CW, Layman TS, Barker DE, Clements JB. Trau- matic abdominal aortic pseudoaneurysm causing biliary obstruction: a case report and review of the literature. J Vasc Surg 1997;25:936-40. 4. Ayella RJ, Hankins JR, Turney SZ, Cowley RA. Ruptured thoracic aorta due to blunt trauma. J Trauma 1977; 17:199- 205. 5. Borioni R, Pace A, Cristell DM, Fittipaldi D, Turani F, Garofalo M, et al. Postumi dei traumi chiusi del torace. Chirurgia 1990;3:455-7. 6. Makins GH. Specimen showing the effects of gunshot injury on the heart and blood vessels. Now on exhibit in the museum of the Royal College of Surgeons of England. Br J Surg 1920;18:141-6. 7. Gonzalez LJ, Gallego GM, Martinez AA. Chronic post- traumatic pseudoaneurysm of the abdominal aorta diag- nosed by duplex Doppler ultrasonography. A case report. Acta Radiol 1997;38:121-3. 8. Does RT, Brouwer KJ. Spontaneous rupture of the abdom- inal aorta without pre-existing aneurysm-two case re- ports. Eur J Vasc Endovasc Surg 1997; 14:408-9. 9. Crawford ES, Saleh SA, Babb JW 3d, Glaeser DH, Vaccaro PS, Silvers A. Infrarenal abdominal aortic aneurysm: fac- tors influencing survival after operation performed over a 25-year period. Ann Surg 1981; 193:699-709. 10. Parodi JC, Palmaz JC, Barone HD. Transfemoral intralu- minal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-9. 11. Parodi JC. Endovascular repair of aortic aneurysms, arteri- ovenous fistulas, and false aneurysms. World J Surg 1996; 20:655-63. 12. White R, Donayre C, Walot I, Kopchok GE, Wilson E, Klein S. Endograft repair of an aortic pseudoaneurysm following gunshot wound injury: impact of imaging on diagnosis and planning ofintervention. J Endovasc Surg 1997;4:344-5 1.

314 Posttraumatic Infrarenal Abdominal Aortic Pseudoaneurysm Volume 26, Number 4, 1999