Steven Ballesteros, MD
Resident Physician
Allegheny General Hospital, United States
Disclosure information not submitted.
Shruthi Thiragarajasubramanian, MD
Assistant Professor
Allegheny General Hospital, United States
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Alan Murdock, MD
General Surgery Residency Program Director
Allegheny General Hospital, United States
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Eunice Chung, MD
Assistant Professor
Allegheny General Hospital, United States
Disclosure information not submitted.
Title: Blunt injury to an abdominal aortic aneurysm: a rare report of traumatic mural thrombus embolism
Case Report Body:
Introduction: Blunt injury to the abdominal aorta is rare and accounts for less than 0.2% of all blunt traumatic injuries. Pre-existing abdominal aortic aneurysms (AAA) may increase the likelihood of aortic injury; however, little data exists in the current literature. We present a case of blunt abdominal aortic injury with traumatic mural thrombus embolism in a patient with a pre-existing AAA.
Description: A 61 year-old male presented to the trauma bay after he was struck in the abdomen by a cement chute. He subsequently developed severe lower extremity pain and weakness. His exam was notable for abdominal wall mottling extending to bilateral thighs. Femoral pulses were palpable, but both feet were cool without dopplerable pedal pulses.
Computed tomography (CT) angiogram revealed a 6.6 cm infrarenal abdominal aortic aneurysm with mural thrombus disruption. All visceral vessels were patent. Emergent angiogram of the lower extremities revealed occlusion of all three right tibial vessels and patent left tibial vessels to the level of the ankle. Thrombectomy was performed of the distal right tibial vessels with removal of mural thrombus. There was persistent occlusion of the digital vessels due to microembolization and intra-arterial nitroglycerin and tissue plasminogen activator failed to revascularize the feet.
Although the patient was immediately anticoagulated, he developed worsening abdominal pain and lactic acidosis. He underwent an exploratory laparotomy which revealed necrosis of the distal ileum and colon necessitating resection. The patient’s post-operative course was complicated by respiratory failure, shock liver, renal failure, rectal stump ischemia requiring low anterior resection, and short gut syndrome requiring total parenteral nutrition. He was eventually weaned off all vasopressors and extubated. The patient developed dry gangrene of both feet which will require amputation.
Discussion: The majority of patients who present with blunt abdominal aortic injury have a high energy mechanism and multiple associated injuries. Generally, the immediate concern is for aortic rupture and hemorrhage. This case represents a very unusual complication of a low energy mechanism leading to mural thrombus embolization from a AAA with subsequent lower extremity ischemia, bowel necrosis, and multi-system organ failure.