|Ahead of print publication
Acute thrombotic occlusion of infrarenal abdominal aorta – rare and catastrophic event after blunt abdominal trauma
Rajneesh Rawat1, Rohit K Chauhan1, Jyoti Baghel2, Avinash Prakash3
1 Department of General Surgery, Trauma Care Center, Government Medical College, Nagpur, Maharashtra, India
2 Department of Obstetrics and Gynaecology, AIIMS, Nagpur, Maharashtra, India
3 Department of Anesthesiology, AIIMS, Nagpur, Maharashtra, India
|Date of Submission||06-Jun-2021|
|Date of Decision||29-Jul-2021|
|Date of Acceptance||30-Mar-2022|
Senior Resident, Trauma Care Center, Government Medical College, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
Acute abdominal aortic occlusion is a rare injury with potentially devastating consequences. Clinically, patients present with severe pain of the bilateral lower limbs with paresthesia or paraplegia. Here, we present a case of thrombotic occlusion of the infrarenal portion of the abdominal aorta with extension to bilateral iliac arteries following a road traffic accident in a young adult. It also highlights the complications associated with thromboemboli arising from blunt abdominal trauma probably due to delayed hospital presentation.
Keywords: Abdominal aorta, acute occlusion, blunt trauma, thromboemboli
|How to cite this URL:|
Rawat R, Chauhan RK, Baghel J, Prakash A. Acute thrombotic occlusion of infrarenal abdominal aorta – rare and catastrophic event after blunt abdominal trauma. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 1]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=346568
| Introduction|| |
Acute abdominal aortic occlusion is a rare phenomenon that requires quick diagnosis and management on account of the high mortality rate. Road traffic incidents are the most common cause of blunt trauma to the abdominal aorta. Post-traumatic acute abdominal aortic occlusion requires timely diagnosis and proper management. Otherwise, it may result in fatal consequences including compartment syndrome, amputation of limbs, myonephropathic metabolic syndrome, renal failure, visceral ischemia, and even death. Management includes prompt recognition, baseline diagnostic workup supportive treatment with anticoagulation. High-dose anticoagulation and embolectomy with Fogarty (Edwards Lifesciences) arterial catheters via bilateral common femoral arteriotomies result in a decrease in mortality and morbidity in patients with acute occlusion from embolism or thrombosis in the aortoiliac artery. Thromboembolectomy using a Fogarty embolectomy catheter is the treatment of choice in cases of acute arterial occlusion.
| Case Report|| |
A 19-year-old boy was brought to the emergency department with a history of road traffic accidents followed by a fall from a two-wheeler over a large stone lying on road. He presented after eight hours following trauma with a complaint of sudden onset of pain in bilateral lower limbs. Pain and paresthesia worsened rapidly in the lower trunk and both legs. He had no significant past medical history.
At admission, his physical examination showed blood pressure (BP) = 150/100 mmHg, tachypnea (respiratory rate-30/min), tachycardia (heart rate = 120 bpm). The abdomen was diffusely tender, guarded, and rigid. Both lower limbs were cold on palpation. There were no palpable pulses in all arterial sites of bilateral lower limbs. Also, complete paresis and areflexia were seen in both lower limbs.
Laboratory analysis showed hemoglobin of 9.2 g/dl and normal serum electrolytes. Coagulation parameters were normal and D-dimer was found to be 416 ng/ml. Transabdominal ultrasound revealed moderate hemoperitoneum. Lower limb Doppler revealed absent color flow and waveform in the aorta below its bifurcation into the common iliac artery. Contrast-enhanced computed tomography (CECT) abdomen and pelvis revealed near-complete noncontrast opacification/thrombotic occlusion of infrarenal part of abdominal aorta for the length of 7.8 cm extending up to its bifurcation suggestive of thrombosis [Figure 1]. Thrombus was partially seen extending in a right common iliac artery (CIA) for the length of 5 mm and left CIA for the length of 12 mm from the bifurcation of the aorta. Also, AAST (The American Association for the Surgery of Trauma) grade III liver injury and AAST grade II right renal injury was noted. Moderate hemoperitoneum and bilateral minimal pneumothorax were also noted.
|Figure 1: Contrast-enhanced CT image: (a) Arrow showing thrombus inside the infrarenal abdominal aorta. (b) Arrow showing injury in segment VI of liver|
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The patient was shifted for emergency surgical intervention. Under general anesthesia, right and left arteriotomy was done following which no flow was noted on both sides. Bilateral proximal femoral embolectomies followed by distal were performed in a step-wise manner using a balloon-tipped Fogarty catheter as shown in [Figure 2]. An acute chronic thrombus material was retrieved from the aorta with satisfactory back flow from both the femoral vessels during the procedure. This was accompanied by a fasciotomy done by the trauma team.
|Figure 2: Showing bilateral femoral artery dissection and thrombus retrieved from the aorta via access through right and left femoral artery|
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After 48 hours of surgical intervention, the patient developed clinical sign of limb ischemia and a line of demarcation was seen over the limb [Figure 3]. Bilateral above-knee amputation was done on the sixth post-operative day. During the rest of his hospital stay, he remained hemodynamically stable and was discharged two weeks later from the hospital.
|Figure 3: Showing necrosed muscle and line of demarcation in the post-operative period|
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| Discussion|| |
Acute aortic occlusion is a rare but catastrophic disease. Shalhub et al. reported the incidence of blunt abdominal aortic injury as 0.07% of all blunt trauma requiring admissions. This rarity is attributed to the well-protected position of the abdominal aorta within the abdomen. Infrarenal abdominal aorta, especially at the iliac bifurcation level, is the most common site although occlusion can be seen in any part of the aorta. Due to the fixed position of the abdominal aorta, a direct blow from trauma can result in contusion due to the stretching and compression of the aortic wall against a high-pressure column of blood. This blow from the trauma that results in contusion, intimal laceration, or dissection can lead to luminal stenosis, thrombosis, or both. Hence, intimal disruption can lead to distal dissection and complete aortic thrombosis. Female gender, smoking, comorbidities like coronary artery disease and diabetes are the risk factors. Various conditions such as dehydration, diabetic ketoacidosis, and heart failure can precipitate occlusion.
The severity of symptoms depends on the extent of aortic injury, from the time of onset of symptoms to and duration required for collateralization. The patient may present with a spectrum of symptoms including low backache, buttock, and lower extremity pain. On examination, motor and sensory deficits are seen in the lower extremities along with the absence of palpable pulses.
Though the diagnosis of acute aortic occlusion can be made based on the clinical symptoms based on distal ischemia and neurologic abnormalities, yet it is confirmed by imaging modalities. Aortography is the gold standard test to confirm the diagnosis of aortic injury though a contrast-enhanced CT scan is more routinely done as an initial diagnostic modality. Doppler ultrasound and magnetic resonance angiography (MRA) are also utilized as a part of diagnostic evaluation.
General supportive treatment includes administration of intravenous heparin, intravenous fluids, and stabilization of the patient. Emergency surgical intervention involves either revascularization by thromboembolectomy or bypass surgery. The surgical technique is dictated by the cause, site, and extent of aortic obstruction, patient comorbidities, and hemodynamic stability at the time of presentation. However, McCullough et al. reported that there was no significant reduction in life expectancy in patients who did not undergo surgical intervention. In the present case, the patient underwent bilateral transfemoral aortoiliac and femoral embolectomies using balloon-tipped Fogarty catheters.
The mortality rate is mainly affected by the onset of clinical symptoms, and the time elapsed to revascularization. In a study by Babu et al., mortality reported due to acute aortic occlusion was 52%. A review by Roth et al. highlighted the need for rapid recognition and timely intervention in potentially lethal injuries due to blunt abdominal aortic trauma. Naude et al. also reported a high mortality rate between 18% and 37% in patients.
Decisions should be made based on the clinical presentation and also detailed history including comorbidities. In the present case, there was a delay in presentation to the hospital, which attributed to the morbidity in the form of ischemic damage to both lower limbs despite doing a surgical intervention. The prognosis mainly depends on making an early diagnosis and thereby, timely reperfusion of critically ischemic tissues. Thus, aortic emergencies remain a diagnostic and treatment challenge for trauma surgeons.
| Conclusion|| |
The case highlights the need to anticipate and diagnose early, subsequently doing an early surgical intervention. A high suspicion index in all cases of blunt trauma to the abdomen is essential to prevent fatal complications like amputations and neurological damage.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]