|Year : 2022 | Volume
| Issue : 4 | Page : 326-328
Ruptured mycotic abdominal aortic aneurysm with perforated colonic malignancy – “Quadruple Jeopardy”
Ashutosh Kumar Pandey, Neelamjingbha Sun, Sriram Manchikanti, Shivanesan Pitchai
Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
|Date of Submission||04-Jan-2022|
|Date of Acceptance||03-Mar-2022|
|Date of Web Publication||8-Nov-2022|
Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
We describe an unusual presentation where a patient referred for ruptured abdominal aortic aneurysm was detected to have a concurrent colonic growth with perforation and localized spillage. Aneurysm repair was done with neoaortoiliac system reconstruction and Hartmann's procedure was done. This case report describes the management of a rare intraoperative challenge.
Keywords: Colon cancer and abdominal aortic aneurysm, mycotic aneurysm, neoaortoiliac system, ruptured mycotic abdominal aortic aneurysm
|How to cite this article:|
Pandey AK, Sun N, Manchikanti S, Pitchai S. Ruptured mycotic abdominal aortic aneurysm with perforated colonic malignancy – “Quadruple Jeopardy”. Indian J Vasc Endovasc Surg 2022;9:326-8
|How to cite this URL:|
Pandey AK, Sun N, Manchikanti S, Pitchai S. Ruptured mycotic abdominal aortic aneurysm with perforated colonic malignancy – “Quadruple Jeopardy”. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Nov 28];9:326-8. Available from: https://www.indjvascsurg.org/text.asp?2022/9/4/326/360537
| Introduction|| |
Concurrent abdominal aortic aneurysm (AAA) and colorectal cancer are rare with a reported incidence of 0.5%–4% in patients with AAA. The surgical dilemma pertains to order of management and strategy of repair. We were posed an even rare challenge where a sexagenarian male with acute abdomen referred for ruptured mycotic AAA has a surprise finding of colonic growth with perforation after laparotomy. Aneurysm was repaired with neoaortoiliac system (NIAS) constructed from bilateral superficial femoral veins (SFV), and for the colonic pathology, Hartmann's procedure was done. The procedure was well tolerated but the patient succumbed to sepsis-related organ dysfunction in the perioperative period.
| Case Discussion|| |
A 64-year-old male presented to the emergency with a history of back pain and fever for the past 1 week with acute worsening of pain for 2 days. He had previous episodes of mild-to-moderate lower back pain for the past 1 year but had not undergone evaluation for the same. On clinical examination, signs of peritonitis were present and laboratory investigation revealed total leukocyte counts of 18,000/mm3. He had been evaluated with a computerized tomographic angiogram at outside center which showed irregular aortic outline and features suggestive of a posterior contained rupture [Figure 1]. There was no gross evidence of colonic pathology in the available radiology images.
|Figure 1: Computed tomography images. (a) Coronal image showing juxtarenal aortic aneurysm with an irregular outline; (b) Reconstructed image|
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Balanced resuscitation protocol was followed and he was shifted for exploratory laparotomy after informed consent. A NAIS was constructed after harvesting bilateral SFV [Figure 2]. A midline laparotomy was done and supraceliac aortic control was taken. Sigmoid loops were densely adhered to the small bowel after mobilization a hard growth and a perforation of 3 cm × 2 cm was noted in the mid-sigmoid [Figure 3]a. Localized fecal contamination was present around the sigmoid loops. Significant amount of blood clots were seen in the retroperitoneum after the bowel was mobilized. After heparinization, supraceliac clamp was applied, aneurysm was opened, and renoplegia was instilled in both renal artery ostia. The proximal end of NAIS was anastomosed to juxtarenal aorta. Distal anastomosis was done to both common iliac arteries [Figure 3]b. Peritoneal lavage was done and omentum was mobilized over NAIS graft. After aortic repair, the sigmoid was resected between clamps and distal rectal stump was closed. The descending colon was brought out as colostomy (Hartmann's procedure). He was shifted to the intensive care unit after surgery. The cultures from aneurysm revealed growth of Enterococcus faecalis. Antibiotics were started as per the sensitivity and he was started on hemodialysis in view of renal dysfunction. Colostomy was functional by day 4 and he was started on oral feeds. Subsequent blood cultures were also positive for E. faecalis and features of sepsis persisted even after hike in antibiotics. He eventually succumbed to sepsis-related multiorgan dysfunction syndrome 2 weeks postsurgery.
|Figure 2: Neoaortoiliac system (a) Bilateral superficial femoral veins after harvest; (b) Superficial femoral veins reconstructed in pantaloon configuration|
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|Figure 3: Intraoperative images. (a) Sigmoid perforation, the contamination was controlled by bowel clamps on both sides; (b) Neoaortoiliac graft anastomosed proximally to juxtarenal aorta and distally to bilateral common iliac arteries|
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| Discussion|| |
Infected AAA arising due to hematogenous, contiguous spread, or direct inosculation of vessel wall is reported to comprise <3% of all cases of aortic aneurysm. Intestinal perforation has a potential to cause infected AAA by all of these mechanisms. The surprise finding of colonic malignancy with perforation in exploration for ruptured mycotic aortic aneurysm is a never-described entity, although appendicular perforation complicating as mycotic AAA has been previously reported., In this case, suspicion for neoplasia was based on the luminal growth noticed intraoperatively which was confirmed on further histopathology. Simultaneous presentation of AAA and colorectal carcinoma is rare and remains a surgical dilemma with regard to the order of treatment and approach., Our index case in view of age and risk factors of smoking was likely to have a secondary infection in preexisting AAA, and the histopathology of aneurysm sac revealed atherosclerotic degeneration which was supportive of the same.
The management of mycotic abdominal aneurysm remains challenging with high rates of morbidity and mortality postoperatively. Claggett et al. in 1993 pioneered the use of autogenous saphenopopliteal veins to replace infected aortoiliac/femoral prostheses. Autogenous reconstruction in the form of NAIS although technically demanding has better outcomes with respect to graft reconstruction with patency rates of 100% being reported. Left colonic malignancy with perforation is also associated with an increased incidence of adverse perioperative outcomes. The Hartmann's procedure has been described for left-sided colonic disease, mainly in emergency scenarios where an anastomosis is prone to complications. In this case, we proceeded with NAIS system as the patient had responded well to resuscitation and the imaging findings along with increased counts were strongly indicative of infected aneurysm. A Hartmann's procedure was done in view of the emergency presentation with rupture and features of sepsis, along with intraoperative hemodynamic instability.
Presence of mycotic, ruptured AAA, and colonic carcinoma with perforation comprised the quadruple challenges. Although the surgery was technically successful, ensuing sepsis led to postoperative mortality. This is a very rare clinical presentation where infected aortic aneurysm was secondary to malignant colonic perforation.
| Conclusion|| |
We describe the management of a rare association of mycotic aneurysm with colonic malignancy and this is the first description of aneurysmal rupture and colonic perforation.
Reconstruction with NAIS along with diversion colostomy was technically feasible to measure although eventually, the patient succumbed to sepsis-related organ dysfunction.
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 his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]