Unusual Problems of Abdominal Aortic Aneurysms Cornelius Olcott, IV, MD, San Francisco, California James W. Holcroft, MD, San Francisco, California Ronald J. Stoney, MD, San Francisco, California Edwin J. Wylie, MD, San Francisco, California
The natural history of infrarenal abdominal aortic aneurysms has been well documented [l-7]. These lesions gradually expand, and given sufficient time without surgical intervention, many will eventually rupture. Hence, the primary reason for elective resection of an abdominal aortic aneurysm is to prevent rupture. However, patients with abdominal aneurysms may present with an unusual clinical picture or develop other complications [8,9] including aortic thrombosis, peripheral embolization, aortocaval fistula, aortoenteric fistula, perianeurysmal inflammation, and retropsoas rupture. The present report describes our experience with these unusual clinical problems. Material
From 1970 to 1976,254 patients were operated on for infrarenal abdominal aortic aneurysm at the University of California, San Francisco. Of these, thirty-one (12 per cent) presented with an unusual clinical manifestation of their aneurysm: aortacaval fistula (3 patients); inflammatory aneurysm (18); aortoenteric fistula (6); aortic thrombosis (2); peripheral embolization (6); and retropsoas rupture (1). Aottocaval
Fistula
Aortocaval fistulas are a recognized, although unusual, complication of abdominal aortic aneurysm [IO-151. Three patients in our series presented with this complication. One patient had a symptomatic 12 cm aneurysm, and at aneurysmectomy two small (2 to 4 mm) aortocaval fistulas were found. The presence of these fistulas had not been appreciated preoperatively, as they produced no demonstrable hemodynamic effect. The remaining two patients presented a characteristic clinical picture: acute moderately severe abdominal pain; congestive heart
From the Department of Surgery, Universityof California School of Medicine, San Francisco, California. Reprint requests should be addressed to Cornelius Olcott. IV, MD, Department of Surgery, University of California School of Medicine, San Francisco, California 94143.
426
failure; rapidly progressive renal failure; lower extremity ischemia with evidence of venous hypertension; and a continuous abdominal bruit. Successful emergency aneurysmectomy was performed on one patient because of suspected rupture, but he died after intraoperative cardiac arrest. The second patient presented with findings compatible with an arteriovenous fistula but without evidence of free intraabdominal rupture. He was initially unstable with severe congestive heart failure and rapidly progressive renal failure. He underwent surgery after a two week period in which his cardiac symptoms improved with cardiotonic drugs and his renal function stabilized after three dialyses. Proximal and distal control of the aneurysm was obtained. The aneurysm was then opened and Fogarty catheters were used to control the venous side of the fistula. (Figure 1.) The fistula was oversewn from within the aneurysm and standard graft replacement carried out. Postoperatively the patient’s renal function returned to normal and his cardiac symptoms cleared. Comment. Reckless, McCall, and Taylor [13] in a review of aortocaval fistulas, found only seventy-one cases reported up to 1972. Baker, Sharzer, and Ehrenhaft [12] reviewed their experience at the University of Iowa and found an aortocaval fistula a complication in 1 per cent of patients operated on for abdominal aortic aneurysm and in 4 per cent of patients with a ruptured aortic aneurysm. The presence of an aortocaval fistula should be suspected in any patient with an abdominal aortic aneurysm who presents with one or more of the following: acute onset of congestive heart failure; bilateral lower extremity venous hypertension with or without distal arterial insufficiency; a continuous abdominal bruit; or renal failure. Arteriography is helpful in diagnosing the fistula but usually is not accurate in delineating its exact location.(Figure 2.1 It is of interest that renal failure was an early finding in both of our patients with hemodynamically
The American Journal of Surgery
Abdominal Aortic Aneurysms
significant fistulas. This is presumed to represent prerenal azotemia, as the renal arteries were not involved in the aneurysm. After resection of the aneurysm and correction of the fistula, renal failure resolved. These aortocaval fistulas should be repaired as soon as possible because progressive cardiac decompensation will occur. Care must be exercised during dissection of the aneurysm to avoid mobilization of debris within the aneurysm and embolization through the fistula. It is best to repair the fistula from within the aneurysm to avoid a potentially dangerous dissection around the fistula. Fogarty catheters have been helpful in controlling the venous side of the fistula, as demonstrated in Figure 1.
Figure 7. The aortocaval fistuia is exposed from within the aneurysm, and proximal and distal control of the venous side is obtained with Fogarty catheters. This allows repair of the fistula from within the aneurysm,
Volume 135, March IS78
InflammatoryAneurysm
Eighteen patients were found to have inflammatory aneurysms at the time of exploration. Abdominal pain of varying severity was the prominent complaint in eight of these patients, although none had a rapidly expanding or ruptured aneurysm. Two other patients were transferred to our hospital after an inflammatory aneurysm was found at an initial exploration elsewhere. In the remaining eight patients, inflammation was an unexpected finding at surgery. All patients had marked inflammation around the aneurysm at laparotomy. (Figure 3.) The duodenum and inferior vena cava were densely adherent to the aneurysm in all patients, and in two patients the transverse mesocolon was also involved. Characteristic of these aneurysms is a pale, shiny exterior, with extensive periaortic inflammation involving the anterior and lateral walls of the aneurysm but sparing the posterior wall, the common iliac arteries, and the proximal 2 to 3 cm of the infrarenal aorta. The wall of the aneurysm is unusually thick (1 to 3 cm) and rigid. Cultures of the aneurysm wall failed to reveal infection. Histologic study of the wall revealed thickening with infiltration by chronic inflammatory cells and occasional calcification. (Figure 4.)
Figure 2. Arteriogram of patient with aortocaval fistula. Arrows point to lateral border of inferior vena ca va ( WC).
427
Olcott et al
Figure 3. Inflammatory aneurysm. Note pale thickened surface of the aneurysm.
Comment. The fact that atherosclerotic aneurysms may be associated with inflammation has been recognized by vascular surgeons, although it has not been often reported. Our experience reveals that the aneurysm is frequently symptomatic in these patients; however, none of the aneurysms reported herein had either a contained or a free rupture. In addition, a review of all ruptured aneurysms at our institution over the same period failed to reveal any with an inflammatory reaction. Presumably the perianeurysmal inflammation is responsible for the pain, and the extensive scarring prohibits rupture. One of the patients in this group presented with a spontaneous aortoduodenal fistula which is understandable in light of the marked adherence to the duodenum to the aneurysm. Dissection around these aneurysms should be performed without separation of adherent bowel from the aneurysm wall. The inflammation obliterates the normal tissue plane between bowel and aneurysm and any attempt to free the bowel from the aneurysm can easily result in inadvertent enterotomy. The duodenum should remain attached to the surface and the aneurysm opened medial to the adherent area. Graft replacement is carried out as usual. None of our patients have subsequently developed a graft infection or an aortoenteric fistula. Aortoenteric Fistula
Figure 4. Histologic se&ion through wall of inflammatory aneurysm demonstrating marked round cell infiltration of the media. ( Magnlficafion X 25; reduced 30 per cent).
420
A fifty-five year old man, who had been evaluated on multiple occasions over an eight month period for recurrent upper gastrointestinal hemorrhage, presented with a spontaneous aortoduodenal fistula. Workup failed to reveal the source of his bleeding, and a 5 cm abdominal aortic aneurysm was the only finding. At laparotomy no gastrointestinal lesion was discovered, although there was a 5 cm inflammatory aneurysm with retroperitoneal edema, and the duodenum was densely adherent to the aneurysm. These findings were thought to be compatible with a spontaneous aortoduodenal fistula involving an inflammatory aneurysm. A left axillofemoral graft was inserted to provide blood flow to the left lower extremity. After appropriate aortic control, the aneurysm was opened and the presence of an aortoduodenal fistula confirmed. The aneurysm was resected and the infrarenal aorta oversewn with monofilament sutures. The common iliac arteries were anastomosed end to end to allow flow from the left axillofemoral graft to the right leg. The duodenum was repaired in two layers. The patient recovered without infection and eight months later underwent aortofemoral bypass grafting with removal of his axillofemoral graft. He remains asymptomatic. The American Journal
of Surgery
Abdominal Aortic Aneurysms
Comment. Primary aortoduodenal fistulas are rare [16,17]. Evans and Webster [17] found only twenty operations had been performed for this condition up to 1972. An aortoduodenal fistula should be suspected, however, in any patient with an abdominal aortic aneurysm and persistent upper gastrointestinal bleeding for which no source can be found. We believe these patients should be managed like patients with infected prosthetic grafts: with resection of the aneurysm and reestablishment of vascular continuity using an axillofemoral graft. The use of an intraabdominal graft in the face of contamination by duodenal contents may lead to future graft infection or recurrent aortoenteric fistula. Aortic Thrombosis
Two patients presented with thrombosis of their aortic aneurysm. Both had a past history of claudication with a recent increase in ischemic complaints. One developed pain and numbness in his lower extremities which slowly improved; the other developed ischemic ulcers on his toes. In both a nonpulsatile aneurysm (7 cm and 8 cm) was noted at examination. Arteriography demonstrated associated occlusive disease of the iliac system with aortic thrombosis. (Figure 5.) Aortofemoral graft replacement resulted in relief of symptoms in both patients. Comment. Thrombosis is a recognized complication of aneurysms, although it is rare in aneurysms of the abdominal aorta [9]. It should be suspected in any patient in whom lower extremity ischemia coexists with a palpable nonpulsatile abdominal aortic aneurysm and absent femoral pulses. Aortography is indicated to demonstrate the extent of associated occlusive disease. Resection of the aneurysm
Figure 6. A, resected abdominal aorik aneurysm 4 opmdafmurysm demonsfrafing fhromfnts and afherosclerofk debris. C and D, lower exfremify pefechiae secondary to embolizafion from aneurysm.
voluma 135, March 1979
Figure 5. Arferiogram of pafienf wifh fhtwMoz& abdominal aorfic aneurysm. Arrows point to wall of aneurysm.
and reconstruction beyond the area of occlusive disease relieve the patient’s symptoms. Peripheral Embolization Six patients presented with peripheral embolization originating from an otherwise asymptomatic abdominal aortic aneurysm. All noted an acute onset of petechial lesions over the lower extremities with multiple areas of muscle pain and tenderness. (Figure 6.) Two patients also had multiple ischemic toes, and another two patients had extremely ischemic lower
Olcott
et al
extremities. One had embolization and occlusion to his left superficial femoral artery; the other had embolization to his left popliteal artery. (Figure 7.) All of these patients were treated by abdominal aortic aneurysmectomy and bilateral lumbar sympathectomy. Two patients required embolectomy of their femoral-popliteal segments. One patient eventually required toe amputation because of digital gangrene. Comment. Aortic aneurysms may be a source of peripheral emboli [18-201. Lord et al [20] encoun-
tered thirty-nine such patients over a four year period, representing 10 per cent of all peripheral embolectomies performed during that period. The emboli were indications for aneurysmectomy in 29 per cent of their patients. We observed two types of embolic episodes: macroemboli causing major vessel occlusion and microemboli resulting in petechiae and small areas of muscle or cutaneous infarction. Both are indications for aneurysmectomy, regardless of the size of the aneurysm. Embolectomy may be required to restore blood flow to the lower extremity if a major vessel has been occluded. Retropsoas Rupture A sixty-three year old man with a 5 cm abdominal aneurysm which had ruptured along its left posterolateral aspect presented with a retropsoas rupture of his aneurysm. The hematoma had dissected behind and into the left psoas muscle. He presented with a pulsatile mass in his left groin, a positive psoas sign, and pain along the distribution of his left femoral nerve. At exploration a contained rupture was found behind the left psoas muscle, dissecting into the left groin. Proximal and distal control of the aneurysm was obtained, and standard graft replacement was performed. The hematoma along the left psoas muscle was evacuated. The patient was asymptomatic postoperatively. Comment. Retropsoas rupture is an unusual presentation for ruptured abdominal aortic aneurysm and results from dissection of the hematoma along the left psoas muscle. This complication was first noted by Razzuk, Linton, and Darling [21] and later by Fletcher and Frankel [22]. Both groups emphasized the necessity for early recognition and prompt correction; a delay in diagnosis can result in a permanent neurologic defect. Therefore, any patient with an abdominal aneurysm and femoral neuropathy should be suspected of having a ruptured abdominal aortic aneurysm. Comments
Figure 7. Arteriogram of patient with an abdominal aorttc aneurysm and an embolus to the distal popliteal artery.
430
Rupture with subsequent hemorrhage remains the primary complication of abdominal aortic aneurysms. At present, elective aneurysmectomy is performed in most vascular surgery centers with acceptably low morbidity and mortality. Free rupture of large untreated aneurysms is thus becoming less common since most aneurysms are treated earlier in their natural course. However, complications other than free rupture may occur. In the present series 12 per cent of all patients admitted for aneurysmectomy
The American Journal of Surgery
Abdominal
had some unusual manifestation of their aneurysm. Recognition of these atypical problems is essential for the proper management of patients with aneurysmal disease. Summary
Complications other than rupture occurred in 12 per cent of 254 patients operated on for an infrarenal abdominal aortic aneurysm. The unusual problems encountered included aortocaval fistula, inflammatory aneurysm, aortoenteric fistula, aortic thrombosis, peripheral embolization, and retropsoas rupture. The clinical manifestations and management of these lesions are discussed. References 1. Estes JE: Abdominal aortic aneurysm: a study of 102 cases. Circulation 2: 258, 1950. 2. Schatz IJ, Fairbairn JF, Juergens JL: Abdominal aortic aneurysms-a reappraisal. Circulation 26: 200, 1962. 3. Klippel AP, Butcher HR: The unoperated abdominal aortic aneurysm. Am J Surg 111: 629, 1966. 4. Szilagyi DE, Smith RF, DeRusso FJ, Elliott JP, Sherrin FW: Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg 164: 678, 1986. 5. Foster JH, Bolasny BL, Gobbel WG, Scott HW: Comparative study of elective resection and expectant treatment of abdominal aortic aneurysms. Surg Gynecol Obstet 129: 1. 1969. 6. Szitagyi DE, Elliott JP, Smith RF: Clinical fate of the patient with an asymptomatic abdominal aortic aneurysm and unfit for surgical treatment. Arch Surg 104: 600, 1972. 7. Bernstein EF, Dilley RB. Goldberger LE, Gosink BB, Leopold GR: Growth rates of small abdominal aortic aneurysms. Surgery
Votume 135, March 1978
Aortic Aneurysms
80: 765, 1976. 8. Moore WS, Preger L, Hall AD, Maddison FE: Abdominal aortic aneurysms: unusual clinical manifestations. Calif AM 108: 345, 1966. 9. Hardy JD, Timmis HH: Abdominal aortic aneurysms: special problems. Ann Surg 173: 945, 1971. 10. Beall AC, Cooley DA, Morris GC, DeBakey ME: Perforation of arteriosclerotic aneurysms into inferior vena cava. Arch Sug 86: 809, 1963. 11. Knox WG, Miller RE, Dwyer EM, Guthrie R: Abdominal aortic aneurysm-vena caval fistula. Ann Surg 164: 947, 1966. 12. Baker WH, Sharzer LA, Ehrenhaft JL: Aortocaval fistula as a complication of abdominal aortic aneurysms. Surgery 72: 933, 1972. 13. Reckless JPD, McCall I, Taylor GW: Aorta-caval fistulae: an uncommon complication of abdominal aortic aneurysms. Br J Surg 59: 461, 1972. 14. Mohr LL, Smith LL: Arteriovenous fistula from rupture of abdominal aortic aneurysm. Arch Surg 110: 806, 1975. 15. Dardik H, Dardik I, Strom MG, Attai L. Carnevale N, Vieth FJ: Intravenous rupture of arteriosclerotic aneurysms of the abdominal aorta. Surgery 80: 647, 1976. 16. Reckless JPD, McCall I, Taylor GW: Aorta-enteric fistulae: an uncommon complication of abdominal aortic aneurysms. Br J Surg 59: 458, 1972. 17. Evans DM. Webster JHH: Spontaneous aortoduodenal fistula. Br J Surg 59: 368, 1972. 18. Crane C: Atherothrombotic embolism to lower extremities in arteriosclerosis. Arch Surg 94: 96, 1967. 19. Darling RC, Austen WG, Linton RR: Arterial embolism. Surg Gynecol Obstet 94: 106, 1967. 20. Lord JW, Rossi G, Daliana M, Drago JR, Schwartz AM: Unsuspected abdominal aortic aneurysms as the cause of peripheral arterial occlusive disease. Ann Surg 177: 767, 1973. 21. Razzuk MD, Linton RR, Darling RC: Femoral neuropathy secondary to ruptured abdominal aortic aneurysms with false aneurysms. JAMA 201: 817. 1967. 22. Fletcher HS, Frankel J: Ruptured abdominal aortic aneurysms presenting with unilateral peripheral neuropathy. Surgery 79: 120, 1976.
431
The natural history of infrarenal abdominal aortic aneurysms has been well documented [l-7]. These lesions gradually expand, and given sufficient time without surgical intervention, many will eventually rupture. Hence, the primary reason for elective resection of an abdominal aortic aneurysm is to prevent rupture. However, patients with abdominal aneurysms may present with an unusual clinical picture or develop other complications [8,9] including aortic thrombosis, peripheral embolization, aortocaval fistula, aortoenteric fistula, perianeurysmal inflammation, and retropsoas rupture. The present report describes our experience with these unusual clinical problems. Material
From 1970 to 1976,254 patients were operated on for infrarenal abdominal aortic aneurysm at the University of California, San Francisco. Of these, thirty-one (12 per cent) presented with an unusual clinical manifestation of their aneurysm: aortacaval fistula (3 patients); inflammatory aneurysm (18); aortoenteric fistula (6); aortic thrombosis (2); peripheral embolization (6); and retropsoas rupture (1). Aottocaval
Fistula
Aortocaval fistulas are a recognized, although unusual, complication of abdominal aortic aneurysm [IO-151. Three patients in our series presented with this complication. One patient had a symptomatic 12 cm aneurysm, and at aneurysmectomy two small (2 to 4 mm) aortocaval fistulas were found. The presence of these fistulas had not been appreciated preoperatively, as they produced no demonstrable hemodynamic effect. The remaining two patients presented a characteristic clinical picture: acute moderately severe abdominal pain; congestive heart
From the Department of Surgery, Universityof California School of Medicine, San Francisco, California. Reprint requests should be addressed to Cornelius Olcott. IV, MD, Department of Surgery, University of California School of Medicine, San Francisco, California 94143.
426
failure; rapidly progressive renal failure; lower extremity ischemia with evidence of venous hypertension; and a continuous abdominal bruit. Successful emergency aneurysmectomy was performed on one patient because of suspected rupture, but he died after intraoperative cardiac arrest. The second patient presented with findings compatible with an arteriovenous fistula but without evidence of free intraabdominal rupture. He was initially unstable with severe congestive heart failure and rapidly progressive renal failure. He underwent surgery after a two week period in which his cardiac symptoms improved with cardiotonic drugs and his renal function stabilized after three dialyses. Proximal and distal control of the aneurysm was obtained. The aneurysm was then opened and Fogarty catheters were used to control the venous side of the fistula. (Figure 1.) The fistula was oversewn from within the aneurysm and standard graft replacement carried out. Postoperatively the patient’s renal function returned to normal and his cardiac symptoms cleared. Comment. Reckless, McCall, and Taylor [13] in a review of aortocaval fistulas, found only seventy-one cases reported up to 1972. Baker, Sharzer, and Ehrenhaft [12] reviewed their experience at the University of Iowa and found an aortocaval fistula a complication in 1 per cent of patients operated on for abdominal aortic aneurysm and in 4 per cent of patients with a ruptured aortic aneurysm. The presence of an aortocaval fistula should be suspected in any patient with an abdominal aortic aneurysm who presents with one or more of the following: acute onset of congestive heart failure; bilateral lower extremity venous hypertension with or without distal arterial insufficiency; a continuous abdominal bruit; or renal failure. Arteriography is helpful in diagnosing the fistula but usually is not accurate in delineating its exact location.(Figure 2.1 It is of interest that renal failure was an early finding in both of our patients with hemodynamically
The American Journal of Surgery
Abdominal Aortic Aneurysms
significant fistulas. This is presumed to represent prerenal azotemia, as the renal arteries were not involved in the aneurysm. After resection of the aneurysm and correction of the fistula, renal failure resolved. These aortocaval fistulas should be repaired as soon as possible because progressive cardiac decompensation will occur. Care must be exercised during dissection of the aneurysm to avoid mobilization of debris within the aneurysm and embolization through the fistula. It is best to repair the fistula from within the aneurysm to avoid a potentially dangerous dissection around the fistula. Fogarty catheters have been helpful in controlling the venous side of the fistula, as demonstrated in Figure 1.
Figure 7. The aortocaval fistuia is exposed from within the aneurysm, and proximal and distal control of the venous side is obtained with Fogarty catheters. This allows repair of the fistula from within the aneurysm,
Volume 135, March IS78
InflammatoryAneurysm
Eighteen patients were found to have inflammatory aneurysms at the time of exploration. Abdominal pain of varying severity was the prominent complaint in eight of these patients, although none had a rapidly expanding or ruptured aneurysm. Two other patients were transferred to our hospital after an inflammatory aneurysm was found at an initial exploration elsewhere. In the remaining eight patients, inflammation was an unexpected finding at surgery. All patients had marked inflammation around the aneurysm at laparotomy. (Figure 3.) The duodenum and inferior vena cava were densely adherent to the aneurysm in all patients, and in two patients the transverse mesocolon was also involved. Characteristic of these aneurysms is a pale, shiny exterior, with extensive periaortic inflammation involving the anterior and lateral walls of the aneurysm but sparing the posterior wall, the common iliac arteries, and the proximal 2 to 3 cm of the infrarenal aorta. The wall of the aneurysm is unusually thick (1 to 3 cm) and rigid. Cultures of the aneurysm wall failed to reveal infection. Histologic study of the wall revealed thickening with infiltration by chronic inflammatory cells and occasional calcification. (Figure 4.)
Figure 2. Arteriogram of patient with aortocaval fistula. Arrows point to lateral border of inferior vena ca va ( WC).
427
Olcott et al
Figure 3. Inflammatory aneurysm. Note pale thickened surface of the aneurysm.
Comment. The fact that atherosclerotic aneurysms may be associated with inflammation has been recognized by vascular surgeons, although it has not been often reported. Our experience reveals that the aneurysm is frequently symptomatic in these patients; however, none of the aneurysms reported herein had either a contained or a free rupture. In addition, a review of all ruptured aneurysms at our institution over the same period failed to reveal any with an inflammatory reaction. Presumably the perianeurysmal inflammation is responsible for the pain, and the extensive scarring prohibits rupture. One of the patients in this group presented with a spontaneous aortoduodenal fistula which is understandable in light of the marked adherence to the duodenum to the aneurysm. Dissection around these aneurysms should be performed without separation of adherent bowel from the aneurysm wall. The inflammation obliterates the normal tissue plane between bowel and aneurysm and any attempt to free the bowel from the aneurysm can easily result in inadvertent enterotomy. The duodenum should remain attached to the surface and the aneurysm opened medial to the adherent area. Graft replacement is carried out as usual. None of our patients have subsequently developed a graft infection or an aortoenteric fistula. Aortoenteric Fistula
Figure 4. Histologic se&ion through wall of inflammatory aneurysm demonstrating marked round cell infiltration of the media. ( Magnlficafion X 25; reduced 30 per cent).
420
A fifty-five year old man, who had been evaluated on multiple occasions over an eight month period for recurrent upper gastrointestinal hemorrhage, presented with a spontaneous aortoduodenal fistula. Workup failed to reveal the source of his bleeding, and a 5 cm abdominal aortic aneurysm was the only finding. At laparotomy no gastrointestinal lesion was discovered, although there was a 5 cm inflammatory aneurysm with retroperitoneal edema, and the duodenum was densely adherent to the aneurysm. These findings were thought to be compatible with a spontaneous aortoduodenal fistula involving an inflammatory aneurysm. A left axillofemoral graft was inserted to provide blood flow to the left lower extremity. After appropriate aortic control, the aneurysm was opened and the presence of an aortoduodenal fistula confirmed. The aneurysm was resected and the infrarenal aorta oversewn with monofilament sutures. The common iliac arteries were anastomosed end to end to allow flow from the left axillofemoral graft to the right leg. The duodenum was repaired in two layers. The patient recovered without infection and eight months later underwent aortofemoral bypass grafting with removal of his axillofemoral graft. He remains asymptomatic. The American Journal
of Surgery
Abdominal Aortic Aneurysms
Comment. Primary aortoduodenal fistulas are rare [16,17]. Evans and Webster [17] found only twenty operations had been performed for this condition up to 1972. An aortoduodenal fistula should be suspected, however, in any patient with an abdominal aortic aneurysm and persistent upper gastrointestinal bleeding for which no source can be found. We believe these patients should be managed like patients with infected prosthetic grafts: with resection of the aneurysm and reestablishment of vascular continuity using an axillofemoral graft. The use of an intraabdominal graft in the face of contamination by duodenal contents may lead to future graft infection or recurrent aortoenteric fistula. Aortic Thrombosis
Two patients presented with thrombosis of their aortic aneurysm. Both had a past history of claudication with a recent increase in ischemic complaints. One developed pain and numbness in his lower extremities which slowly improved; the other developed ischemic ulcers on his toes. In both a nonpulsatile aneurysm (7 cm and 8 cm) was noted at examination. Arteriography demonstrated associated occlusive disease of the iliac system with aortic thrombosis. (Figure 5.) Aortofemoral graft replacement resulted in relief of symptoms in both patients. Comment. Thrombosis is a recognized complication of aneurysms, although it is rare in aneurysms of the abdominal aorta [9]. It should be suspected in any patient in whom lower extremity ischemia coexists with a palpable nonpulsatile abdominal aortic aneurysm and absent femoral pulses. Aortography is indicated to demonstrate the extent of associated occlusive disease. Resection of the aneurysm
Figure 6. A, resected abdominal aorik aneurysm 4 opmdafmurysm demonsfrafing fhromfnts and afherosclerofk debris. C and D, lower exfremify pefechiae secondary to embolizafion from aneurysm.
voluma 135, March 1979
Figure 5. Arferiogram of pafienf wifh fhtwMoz& abdominal aorfic aneurysm. Arrows point to wall of aneurysm.
and reconstruction beyond the area of occlusive disease relieve the patient’s symptoms. Peripheral Embolization Six patients presented with peripheral embolization originating from an otherwise asymptomatic abdominal aortic aneurysm. All noted an acute onset of petechial lesions over the lower extremities with multiple areas of muscle pain and tenderness. (Figure 6.) Two patients also had multiple ischemic toes, and another two patients had extremely ischemic lower
Olcott
et al
extremities. One had embolization and occlusion to his left superficial femoral artery; the other had embolization to his left popliteal artery. (Figure 7.) All of these patients were treated by abdominal aortic aneurysmectomy and bilateral lumbar sympathectomy. Two patients required embolectomy of their femoral-popliteal segments. One patient eventually required toe amputation because of digital gangrene. Comment. Aortic aneurysms may be a source of peripheral emboli [18-201. Lord et al [20] encoun-
tered thirty-nine such patients over a four year period, representing 10 per cent of all peripheral embolectomies performed during that period. The emboli were indications for aneurysmectomy in 29 per cent of their patients. We observed two types of embolic episodes: macroemboli causing major vessel occlusion and microemboli resulting in petechiae and small areas of muscle or cutaneous infarction. Both are indications for aneurysmectomy, regardless of the size of the aneurysm. Embolectomy may be required to restore blood flow to the lower extremity if a major vessel has been occluded. Retropsoas Rupture A sixty-three year old man with a 5 cm abdominal aneurysm which had ruptured along its left posterolateral aspect presented with a retropsoas rupture of his aneurysm. The hematoma had dissected behind and into the left psoas muscle. He presented with a pulsatile mass in his left groin, a positive psoas sign, and pain along the distribution of his left femoral nerve. At exploration a contained rupture was found behind the left psoas muscle, dissecting into the left groin. Proximal and distal control of the aneurysm was obtained, and standard graft replacement was performed. The hematoma along the left psoas muscle was evacuated. The patient was asymptomatic postoperatively. Comment. Retropsoas rupture is an unusual presentation for ruptured abdominal aortic aneurysm and results from dissection of the hematoma along the left psoas muscle. This complication was first noted by Razzuk, Linton, and Darling [21] and later by Fletcher and Frankel [22]. Both groups emphasized the necessity for early recognition and prompt correction; a delay in diagnosis can result in a permanent neurologic defect. Therefore, any patient with an abdominal aneurysm and femoral neuropathy should be suspected of having a ruptured abdominal aortic aneurysm. Comments
Figure 7. Arteriogram of patient with an abdominal aorttc aneurysm and an embolus to the distal popliteal artery.
430
Rupture with subsequent hemorrhage remains the primary complication of abdominal aortic aneurysms. At present, elective aneurysmectomy is performed in most vascular surgery centers with acceptably low morbidity and mortality. Free rupture of large untreated aneurysms is thus becoming less common since most aneurysms are treated earlier in their natural course. However, complications other than free rupture may occur. In the present series 12 per cent of all patients admitted for aneurysmectomy
The American Journal of Surgery
Abdominal
had some unusual manifestation of their aneurysm. Recognition of these atypical problems is essential for the proper management of patients with aneurysmal disease. Summary
Complications other than rupture occurred in 12 per cent of 254 patients operated on for an infrarenal abdominal aortic aneurysm. The unusual problems encountered included aortocaval fistula, inflammatory aneurysm, aortoenteric fistula, aortic thrombosis, peripheral embolization, and retropsoas rupture. The clinical manifestations and management of these lesions are discussed. References 1. Estes JE: Abdominal aortic aneurysm: a study of 102 cases. Circulation 2: 258, 1950. 2. Schatz IJ, Fairbairn JF, Juergens JL: Abdominal aortic aneurysms-a reappraisal. Circulation 26: 200, 1962. 3. Klippel AP, Butcher HR: The unoperated abdominal aortic aneurysm. Am J Surg 111: 629, 1966. 4. Szilagyi DE, Smith RF, DeRusso FJ, Elliott JP, Sherrin FW: Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg 164: 678, 1986. 5. Foster JH, Bolasny BL, Gobbel WG, Scott HW: Comparative study of elective resection and expectant treatment of abdominal aortic aneurysms. Surg Gynecol Obstet 129: 1. 1969. 6. Szitagyi DE, Elliott JP, Smith RF: Clinical fate of the patient with an asymptomatic abdominal aortic aneurysm and unfit for surgical treatment. Arch Surg 104: 600, 1972. 7. Bernstein EF, Dilley RB. Goldberger LE, Gosink BB, Leopold GR: Growth rates of small abdominal aortic aneurysms. Surgery
Votume 135, March 1978
Aortic Aneurysms
80: 765, 1976. 8. Moore WS, Preger L, Hall AD, Maddison FE: Abdominal aortic aneurysms: unusual clinical manifestations. Calif AM 108: 345, 1966. 9. Hardy JD, Timmis HH: Abdominal aortic aneurysms: special problems. Ann Surg 173: 945, 1971. 10. Beall AC, Cooley DA, Morris GC, DeBakey ME: Perforation of arteriosclerotic aneurysms into inferior vena cava. Arch Sug 86: 809, 1963. 11. Knox WG, Miller RE, Dwyer EM, Guthrie R: Abdominal aortic aneurysm-vena caval fistula. Ann Surg 164: 947, 1966. 12. Baker WH, Sharzer LA, Ehrenhaft JL: Aortocaval fistula as a complication of abdominal aortic aneurysms. Surgery 72: 933, 1972. 13. Reckless JPD, McCall I, Taylor GW: Aorta-caval fistulae: an uncommon complication of abdominal aortic aneurysms. Br J Surg 59: 461, 1972. 14. Mohr LL, Smith LL: Arteriovenous fistula from rupture of abdominal aortic aneurysm. Arch Surg 110: 806, 1975. 15. Dardik H, Dardik I, Strom MG, Attai L. Carnevale N, Vieth FJ: Intravenous rupture of arteriosclerotic aneurysms of the abdominal aorta. Surgery 80: 647, 1976. 16. Reckless JPD, McCall I, Taylor GW: Aorta-enteric fistulae: an uncommon complication of abdominal aortic aneurysms. Br J Surg 59: 458, 1972. 17. Evans DM. Webster JHH: Spontaneous aortoduodenal fistula. Br J Surg 59: 368, 1972. 18. Crane C: Atherothrombotic embolism to lower extremities in arteriosclerosis. Arch Surg 94: 96, 1967. 19. Darling RC, Austen WG, Linton RR: Arterial embolism. Surg Gynecol Obstet 94: 106, 1967. 20. Lord JW, Rossi G, Daliana M, Drago JR, Schwartz AM: Unsuspected abdominal aortic aneurysms as the cause of peripheral arterial occlusive disease. Ann Surg 177: 767, 1973. 21. Razzuk MD, Linton RR, Darling RC: Femoral neuropathy secondary to ruptured abdominal aortic aneurysms with false aneurysms. JAMA 201: 817. 1967. 22. Fletcher HS, Frankel J: Ruptured abdominal aortic aneurysms presenting with unilateral peripheral neuropathy. Surgery 79: 120, 1976.
431
