Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 326-328

Ruptured mycotic abdominal aortic aneurysm with perforated colonic malignancy – “Quadruple Jeopardy


Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Submission04-Jan-2022
Date of Acceptance03-Mar-2022
Date of Web Publication8-Nov-2022

Correspondence Address:
Shivanesan Pitchai
Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_1_22

Rights and Permissions
  Abstract 


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 Top


Concurrent abdominal aortic aneurysm (AAA) and colorectal cancer are rare with a reported incidence of 0.5%–4% in patients with AAA.[1] The surgical dilemma pertains to order of management and strategy of repair.[2] 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 Top


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

Click here to view


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

Click here to view
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

Click here to view



  Discussion Top


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.[3] Intestinal perforation has a potential to cause infected AAA by all of these mechanisms.[4] 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.[4],[5] 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.[1],[2] 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.[6] Claggett et al. in 1993 pioneered the use of autogenous saphenopopliteal veins to replace infected aortoiliac/femoral prostheses.[7] 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.[8] Left colonic malignancy with perforation is also associated with an increased incidence of adverse perioperative outcomes.[9] The Hartmann's procedure has been described for left-sided colonic disease, mainly in emergency scenarios where an anastomosis is prone to complications.[10] 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kouvelos GN, Patelis N, Antoniou GA, Lazaris A, Bali C, Matsagkas M. Management of concomitant abdominal aortic aneurysm and colorectal cancer. J Vasc Surg 2016;63:1384-93.  Back to cited text no. 1
    
2.
Shalhoub J, Naughton P, Lau N, Tsang JS, Kelly CJ, Leahy AL, et al. Concurrent colorectal malignancy and abdominal aortic aneurysm: A multicentre experience and review of the literature. Eur J Vasc Endovasc Surg 2009;37:544-56.  Back to cited text no. 2
    
3.
Ishizaka N, Sohmiya K, Miyamura M, Umeda T, Tsuji M, Katsumata T, et al. Infected aortic aneurysm and inflammatory aortic aneurysm – In search of an optimal differential diagnosis. J Cardiol 2012;59:123-31.  Back to cited text no. 3
    
4.
Cuijpers AC, de Boer SW, van der Leij C, Coolsen MM. Case report of multiple mesenteric mycotic aneurysms after perforated appendicitis. Int J Surg Case Rep 2021;79:331-4.  Back to cited text no. 4
    
5.
Morrow DR, Boyle JR. Ruptured infected aneurysm of the aorta secondary to appendicitis. EJVES Extra 2005;9:11-2.  Back to cited text no. 5
    
6.
Oderich GS, Panneton JM, Bower TC, Cherry KJ Jr., Rowland CM, Noel AA, et al. Infected aortic aneurysms: Aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;34:900-8.  Back to cited text no. 6
    
7.
Clagett GP, Bowers BL, Lopez-Viego MA, Rossi MB, Valentine RJ, Chervu A, et al. Creation of a neo-aortoiliac system from lower extremity deep and superficial veins. Ann Surg 1993;218:239.  Back to cited text no. 7
    
8.
Klonaris C, Patelis N, Katsargyris A, Athanasiadis D, Alexandrou A, Liakakos T. Neoaortoiliac system procedure to treat infected aortic grafts. Ann Vasc Surg 2017;44:419.e19-25.  Back to cited text no. 8
    
9.
Bielecki K, Kamiński P, Klukowski M. Large bowel perforation: Morbidity and mortality. Tech Coloproctol 2002;6:177-82.  Back to cited text no. 9
    
10.
Barbieux J, Plumereau F, Hamy A. Current indications for the Hartmann procedure. J Visc Surg 2016;153:31-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case Discussion
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed156    
    Printed2    
    Emailed0    
    PDF Downloaded67    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]