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PATIENT STORY

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A 65-year-old man presented to the emergency room with complaints of abdominal pain. He described the pain to be stabbing in nature, radiating to his back and very severe (10 on a scale of 0-10). His past medical history was significant for smoking, hypertension, diabetes, and coronary artery heart disease. On physical examination, he was found to be tachycardic and hypotensive. On abdominal examination, there was a large pulsatile mass in his abdomen. Both femoral pulses were palpable but weak. A computed tomographic (CT) scan of his abdomen showed that there was loss of the fat plane between the aorta and the surrounding tissues and a large retroperitoneal hematoma (Figures 30-1 and 30-2).

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FIGURE 30-1

Computed tomographic (CT) scan of abdomen showing a left retroperitoneal hematoma.

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FIGURE 30-2

Computed tomographic (CT) scan of abdomen showing loss of fat plane between the aorta and the surrounding tissues. A retroperitoneal hematoma is also visible.

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TREATMENT COURSE FOR THE PATIENT

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  • The patient was brought to the operating room, and under local anesthetic, bilateral groin cut-downs were performed, exposing both common femoral arteries. An occluding balloon was passed via right femoral artery and was inflated proximal to the aneurysm sac, thus temporarily occluding blood flow to the aneurysm.

  • A diagnostic catheter was passed via left femoral artery, and an aortogram was performed, identifying the location of both renal and internal iliac arteries.

  • Main body of endovascular graft was then deployed via the left femoral artery. Occluding balloon was then placed proximally via the left common femoral artery (Figure 30-3). Then, via the right common femoral artery, the right limb of the endograft was deployed, and then via the left common femoral artery, the left limb of the endograft was deployed (Figure 30-4).

  • Balloon insufflation was performed at proximal and distal ends of the endograft and a completion aortogram was performed, which showed that the aneurysm cavity was effectively excluded (Figure 30-5).

  • The patient's postoperative course was uneventful, and he was discharged home on the fourth postoperative day.

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FIGURE 30-3

Occluding balloon, inserted via left common femoral artery and occluding blood flow into the aneurysm sac.

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FIGURE 30-4

Main body of endograft has been deployed and retrograde aortogram shows a leak from the ruptured aneurysm sac.

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FIGURE 30-5

Endograft has been deployed and completion angiogram shows that the aneurysm sac has been completely excluded and there is no leakage of blood flow.

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