Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 322-325

COVID-19-positive ruptured abdominal aortic aneurysm successfully managed by open surgical repair and review of literature


1 Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Radiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission30-Jul-2021
Date of Acceptance04-Sep-2021
Date of Web Publication8-Nov-2022

Correspondence Address:
Ajay Savlania
Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_86_21

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  Abstract 


COVID-19 pandemic has affected everyone globally in every walk of life. A rise in the number of patients afflicted with thromboembolic complications of COVID-19 is being reported, both venous and arterial. Elective vascular surgery has been stopped entirely at our institute. However, both COVID-19-positive and negative patients continued to require emergent vascular surgery even during the pandemic. We are reporting a case of COVID-positive, ruptured abdominal aortic aneurysm (AAA) who was successfully managed at our hospital. The principles of open repair of ruptured AAA remained same, with a few special considerations. We did not find any report on open repair of ruptured AAA in COVID-19-positive patient. On search at Medline, we found two cases of ruptured AAA, which were successfully managed with endovascular aneurysm repair (EVAR).

Keywords: COVID pandemic, COVID-19, open surgical repair, ruptured aortic aneurysm


How to cite this article:
Abuji K, Savlania A, Kumar D, Kaman L, Gorsi U, Tandup C. COVID-19-positive ruptured abdominal aortic aneurysm successfully managed by open surgical repair and review of literature. Indian J Vasc Endovasc Surg 2022;9:322-5

How to cite this URL:
Abuji K, Savlania A, Kumar D, Kaman L, Gorsi U, Tandup C. COVID-19-positive ruptured abdominal aortic aneurysm successfully managed by open surgical repair and review of literature. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Nov 28];9:322-5. Available from: https://www.indjvascsurg.org/text.asp?2022/9/4/322/360551




  Introduction Top


With second wave of the COVID-19 pandemic, the Indian health-care system is overburdened with rising toll of patients. In Chandigarh, the capital of Punjab and Haryana, the majority of hospital resources are directed toward supporting beds for COVID patients. Elective surgery at our postgraduate institute of medical education and research is standstill; however, vascular surgery emergencies are addressed regularly. We are reporting a case of COVID-positive, ruptured abdominal aortic aneurysm (AAA) who was successfully managed with open surgical repair at our hospital. The standard principles of open repair of ruptured AAA remained same, with a few special considerations. We did not find literature on open repair of ruptured AAA in COVID-19-positive patient as above. The patient consent was obtained to publish this case report.


  Case Report Top


A 49-year-old male, atherosclerotic, presented to the emergency department with acute onset of abdominal pain radiating to the back. The pain started 10 days after he fell from the stairs, which was initially moderate intensity, became progressively worse, and associated with abdominal distension. His medical history was unremarkable except that he is a chronic alcoholic with a daily intake of more than 180 ml/day for the past 30 years. On presentation, he appeared in discomfort due to pain with extreme diaphoresis. His blood pressure was 160/100 mmHg; pulse rate was 90/min; respiratory rate was 20/min, oxygen saturation was 95% on room air, and the temperature was 38.5°C. On physical examination of the chest, there was decreased basal air entry, regular heart rate, and rhythm. On abdominal examination, it was distended obese abdomen, diffuse tenderness on deep palpation with pulsatile mass palpable in periumbilical region, severe ecchymosis over left flank, and back-like Grey Turner's sign in severe hemorrhagic pancreatitis. Bilateral lower limb pulses were palpable.

His blood investigations showed hemoglobin 10.2 gm/dl, platelets 1.42 lakh/mm3, creatinine was 2.53 mg/dL, normal liver function test, and normal prothrombin time of 14 s. As per the institutes' protocol, his reverse transcription-polymerase chain reaction (RT-PCR) was done at admission, in the red area of emergency, which was positive. His quantitative D-dimer levels were very high 2398 ng/ml, C-reactive protein was on the higher side 76 mg/l, serum fibrinogen 2.79 gm/l, and ferritin level was 369.4 ng/ml. Due to high creatinine levels, we decided to perform noncontrast-computed tomography (CT) of the chest and abdomen. It showed a fusiform aneurysm of the infrarenal aorta 7.3 cm diameter and 12.5 cm of length up to aortic bifurcation with >3 cm neck suitable for endovascular repair though it was not performed for financial reasons [Figure 1]a. There was a large 9.1 cm × 6.6 cm × 16.7 cm size retroperitoneal hematoma along the entire length of the left psoas muscle [Figure 1]b. The patient was planned for open aortic repair, as there were financial constraints for endovascular therapy. A high-resolution CT revealed bilateral moderate pleural effusion and no changes in the lung parenchyma. He was shifted to our COVID patient care dedicated hospital on our campus, equipped for surgery in COVID-positive patients.
Figure 1: (a) Computed tomography scan abdomen, noncontrast, axial section, showing aortic aneurysm (red arrow), and retroperitoneal hematoma (arrow head). (b) Computed tomography scan abdomen, coronal section showing aneurysm, with calcification in wall of aneurysm and surrounding hematoma (arrow)

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The procedure was performed with proper personal protective equipment (PPE) for all operating room staff. On exploration after midline laparotomy, 400 ml of blood was there in the peritoneal cavity. The liver was found to have cirrhotic changes. Due to ruptured aneurysm status, we did not give unfractionated heparin. Proximal aortic control was taken at the level of the infrarenal aorta, and distal aortic control was planned intraluminal as anatomy was disturbed at aortic bifurcation. The aneurysm sac was opened, and 250 g of organized clot was removed from the aneurysm sac, and distal control was obtained by intraluminal use of balloon catheters. As blood was clotting in the surgical field, we quickly gave 1 mg/kg unfractionated heparin to achieve an activated clotting time of >250 s. A 16 mm coated polyester graft tube was anastomosed proximally with an infrarenal healthy neck plus it was reinforced with Teflon felt. The distal anastomosis was done on aortic bifurcation, and flow was restored with back-and-forth de-airing of graft. After the complete repair of aneurysm, bilateral femoral pulses were checked, which was palpable in the left groin but impalpable on the right side. Immediately, we exposed the right femoral artery; retrograde and antegrade thrombectomy was done. However, antegrade flow was not normal on the right side, so a jump graft of 8 mm coated polyester was anastomosed end to side with tubular aortic graft, tunneled to the groin, and anastomosed distally with common femoral artery [Figure 2]. Although we repeated the injection of unfractionated heparin of half-dose at 1 h, the 8 mm graft limb thrombosed, we did graft thrombectomy twice, and finally, we achieved palpable pulse in the right femoral artery. Due to abdominal distention, we did not do abdominal sheath closure, and skin was only approximated. We were expecting ascites postoperatively, so we placed an intraperitoneal closed drain system. Skin closure compared to temporary Bogota bag closure makes the management of ascites relatively easy. He required a ventilator postoperatively for more than 24 h. For the initial 5 days, we gave albumin infusion of albumin 100 ml (20%) to decrease the risk of ascites formation and allow healing of the skin. He had a daily loss of ascitic fluid in the drain of 250–400 ml for a week, and the drain was removed on 9th postoperative day. His hemogram and renal function test remained normal in the postoperative period. However, his liver function tests were deranged compared to preoperative reports for a week time. Serum bilirubin increased to 4 gm/dl, alanine and aspartate serum transferase levels increased to 180 and 218 units/L, respectively, and gradually normalized over the week. His prothrombin time was also deranged 24 s, which got normalized over 72 h after treatment with fresh frozen plasma. We started him on unfractionated heparin after 5 days with prophylactic dose, 5000 units subcutaneous thrice a day. He had waxing and waning fever due to COVID-19 infection in the postoperative period, managed with tepid sponging and antipyretics. He has been discharged to home on rivaroxaban 10 mg for 4 weeks, under home quarantine. At discharge, his distal pulses in lower limbs were palpable with healthy limbs. At 2 months of follow-up, he is healthy and has palpable pulses in lower limbs.
Figure 2: Intraoperative picture showing tubular coated polyester graft used for aneurysm repair (yellow arrow) and 8 mm coated polyester jump graft used for bypass to right femoral artery (green arrow)

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  Discussion Top


The COVID-19 pandemic has affected globally everyone in every walk of life, including all health-care services. A rise in the number of patients afflicted with thromboembolic complications of COVID-19 is being reported, both venous and arterial.[1],[2] Elective vascular surgery has been entirely stopped at our institute. However, both COVID-19-positive and negative patients continued to require emergent vascular surgery during a pandemic.

The patient described here had a ruptured AAA with the free rupture. With the increase in severity of pain and repeated episodes of fever, he was brought to our emergency services. On mandatory workup, including RT-PCR for COVID, he was found to be COVID-19 positive. This 49-year-old gentleman with relatively good potential for survival, not offering available open repair with COVID-19 being positive, was not an option. However, care of the patient with a ruptured aneurysm during this COVID pandemic does require special consideration regarding the type of surgery and anesthesia.[3],[4] His treatment still followed the standard protocols for a ruptured aortic aneurysm. We chose the open repair due to financial reasons. However, endovascular is the first line of management recommended by the 2018 Society of Vascular Surgery guidelines, and logically endovascular aneurysm repair (EVAR) under local anesthesia would be more favorable as it would avoid the need for a ventilator.[5] On search at Medline so far, only two cases of rupture AAA are reported and both were managed with EVAR due to obvious reason to prevent the spread of infection by avoiding intubation, need of postoperative ventilator requirement.[3],[4] Our center is a high-volume center for open aortic aneurysm repair, and we do not have a hybrid operation room at our center. At the time of this patient's presentation, our hospital had already set up a dedicated OR for COVID-19-positive patients. This room was equipped with portable high-efficiency particulate air filtration units. On entry into the dedicated COVID center, COVID carts were placed with bundles of complete PPE. After PPE was donned, we entered our surgical operation room, and we ''scrubbed'' the gloves with chlorhexidine gluconate 1% and ethyl alcohol 61% solution, then put on sterile gown and gloves over everything. We utilized two circulating nurses, one inside the OR and one outside the OR, to prevent repeated entering and exiting. After surgery, the patient was kept in the intensive care unit; after recovery in ICU and extubation, the patient was transferred to a dedicated COVID care ward.

The accompanying fever due to COVID-19 infection raised additional concerns. Although it is primarily a respiratory infection, some patients develop systemic involvement.[6] The effect of implanting a graft in an active COVID-19 condition is unknown. The potential increased risk of limb thrombosis was taken into account as these patients are thought to be in a prothrombotic state.[2] After the procedure, we immediately resumed aspirin, but statins were delayed due to deranged liver functions. Fortunately, our patient after intraoperative thrombotic events, he did not have postoperative thrombotic events, and importantly, we were more worried about bleeding than thrombosis at presentation. However, as more and more arterial thrombotic complications are being reported, we feel a short course of anticoagulation after aortic graft implantation with either heparin or novel oral anticoagulant would be justified until the COVID-19 infection is cleared. Equally important, intubation is a major aerosol-producing procedure, potentially threatening all personnel in the operating room.[7] All the OR personnel were present for almost 5 h in the operation theater, and many of us had significant fogging of eye covers, which sometimes lead to difficult visualization. None of our team member, including surgical, anesthesia, and paramedical staff, had any signs of COVID infection in the perioperative period; thanks to the dedicated team in the doffing area, which guided us, how to stepwise do doffing of PPE, they continuously monitor us by CCTV camera and guided by audio message on speakers in doffing area. No antiviral therapy was required because in the present case lung parenchyma was clear from any COVID-related changes.


  Conclusion Top


Ruptured AAA in COVID-19-positive patients can be treated with open repair with satisfactory early outcome particularly, where endovascular facilities are not available. Hospital preparedness during a pandemic is vital to success in emergent operations. The long-term effects of implanting a graft during an active COVID-19 infection are unknown and will need to be monitored.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bellosta R, Luzzani L, Natalini G, Pegorer MA, Attisani L, Cossu LG, et al. Acute limb ischemia in patients with COVID-19 pneumonia. J Vasc Surg 2020;72:1864-72.  Back to cited text no. 1
    
2.
Klok FA, Kruip MJ, van der Meer NJ, Arbous MS, Gommers DA, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.  Back to cited text no. 2
    
3.
Verikokos C, Lazaris AM, Geroulakos G. Doing the right thing for the right reason when treating ruptured abdominal aortic aneurysms in the COVID-19 era. J Vasc Surg 2020;72:373-4.  Back to cited text no. 3
    
4.
Shih M, Swearingen B, Rhee R. Ruptured abdominal aortic aneurysm treated with endovascular repair in a patient with active COVID-19 infection during the pandemic. Ann Vasc Surg 2020;66:14-7.  Back to cited text no. 4
    
5.
Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, et al. The society for vascular surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018;67:2-77.e2.  Back to cited text no. 5
    
6.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 6
    
7.
Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012;7:e35797.  Back to cited text no. 7
    


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