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CASE REPORT
Abdominal aortic pseudoaneurysm diagnosed 42 years after abdominal gunshot wound
André Brito Queiroz
Corresponding author
andrebrito01@hotmail.com

Tel.: 55 11 3069-6101
, Erasmo Simao da Silva, Ricardo Aun, Daniel Augusto Benitti, Vinicius Bertoldi, Pedro Puech-Leão
Department of Surgery, Vascular and Endovascular Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Traumatic pseudoaneurysm of the abdominal aorta is a life threatening and a rare condition in aortic injuries&#46; Most lesions are caused by a penetrating injury and may not be detected during the first evaluation&#46; The time interval from initial trauma to appearance of clinical signs and symptoms may range from a few days to many years&#44; and there are only a few reports of delayed presentation&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">We describe the case of a 59-year-old man who presented with abdominal pain 42 years after an abdominal gunshot injury&#46; A traumatic pseudoaneurysm of the infrarenal abdominal aorta was diagnosed&#46; Resection of the pseudoaneurysm and a Dacron graft interposition were the treatment&#44; and there were no postoperative complications&#46; The time interval from injury to diagnosis of the traumatic abdominal aorta pseudoaneurysm is the longest found in the literature&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE REPORT</span><p id="para30" class="elsevierStylePara elsevierViewall">A 59-year-old man presented with a history of mild abdominal pain in the lower abdomen for almost a year&#46; The pain had become severe&#44; with radiating to his back&#44; in the 4 days before the patient was seen in our hospital&#46; His medical history included an exploratory laparotomy after an abdominal gunshot injury 42 years earlier&#46; The bullet had entered the epigastrium and did not exit the abdomen&#46; Information about the initial laparotomy was limited because his medical records were not available&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Physical examination revealed that the patient was afebrile and hemodynamically stable &#40;heart rate 72 beats&#47;min&#59; blood pressure 120&#47;90 mmHg&#41;&#46; His abdomen was soft&#44; and he had mild pain on palpation of the umbilical region&#59; there was no pulsatile mass&#46; Lower limb pulses were normal&#44; and laboratory tests showed no relevant abnormalities&#46; Contrast-enhanced CT revealed a metal fragment&#44; probably a bullet&#44; impacted in the vertebral body of S1&#44; and a pseudoaneurysm measuring 5&#46;3 cm in diameter in the anterior wall of the infrarenal aorta &#40;<a class="elsevierStyleCrossRefs" href="#fig1">Figures 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para50" class="elsevierStylePara elsevierViewall">The patient underwent a laparotomy with midline incision&#46; The pseudoaneurysm was in the anterior wall of the infrarenal aorta and there were no signs of local infection or pseudoaneurysm rupture&#46; Repair was performed with resection and placement of an 18 mm Dacron tubular graft with end-to-end anastomosis&#46; During the procedure&#44; embolization of the lower limbs occurred&#44; and bilateral femoral embolectomy was performed successfully&#46; No blood transfusion was required&#44; and the patient remained stable during the procedure&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">The aortic wall cultures were all negative&#59; the patient had an uneventful recovery and was discharged 7 days later&#46; At 1-year follow-up examination&#44; he remained asymptomatic&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para70" class="elsevierStylePara elsevierViewall">Penetrating aortic trauma is a severe condition&#44; and its mortality rate has remained high despite recent advances in trauma care&#46; The retroperitoneal position of the abdominal aorta and the large amount of surrounding tissue may result in a tamponade of the local hemorrhage&#46; The absorption of this contained hematoma and the fibrosis of surrounding tissues may lead to the formation of a chronic pseudoaneurysm&#44; a rare and severe complication of aortic injuries&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a></p><p id="para80" class="elsevierStylePara elsevierViewall">Only a few reports have been published since Makins described the first case in 1920&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> In a review conducted by Chase et al&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> 24 cases of traumatic abdominal aortic pseudoaneurysm were indentified&#46; Its usual initial presentation is abdominal or back pain&#44; but a pulsatile abdominal mass may also be detected&#44; as well as thromboembolism&#44; compression of adjacent structures&#44; gastrointestinal bleeding and sudden rupture&#44; which is a lethal presentation&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;3&#8211;5</a> Clinical signs may be detected from a few days to many years after the injury&#46; The case reported here&#44; with clinical signs and symptoms detected 42 years after the trauma&#44; had the longest time interval from injury to diagnosis ever described&#46; In 1997&#44; Chase et al&#46; reported a case diagnosed 32 years after the initial lesion&#44; and their patient had biliary obstruction and jaundice owing to pseudoaneurysm enlargement&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> These lesions seem to grow slowly over the years&#46; The diameter may be the main cause of the compression symptoms and may be associated with the hemodynamic stress on the pseudoaneurysm walls and their risk of rupture&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">This is an unusual pathology with a wide variability of presentations&#46; Therefore&#44; its diagnosis is usually difficult and greatly dependent on imaging studies&#46; Contrast-enhanced CT has an important role in diagnosing and surgical planning because it can reveal where the lesion is&#44; its extension and its relation to adjacent structures&#46; Moreover&#44; it is usually readily available in trauma care centers and is less invasive than aortography&#46; CT also has high sensitivity and may be used alone to diagnose most cases of this type of pseudoaneurysm&#46;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;7</a></p><p id="para100" class="elsevierStylePara elsevierViewall">Surgery may be performed using an open technique for primary aortorrhaphy&#44; patch aortoplasty or resection with graft placement&#44;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;8</a> or an endovascular technique for endoprosthesis placement&#46; When the location is infrarenal&#44; pseudoaneurysm resection and graft interposition is the preferred treatment according to other cases reported in the literature&#44; and we adopted this technique because the patient was young and in good health&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;4</a> In selected patients&#44; the endovascular approach has been effective and avoids a hostile abdomen and retroperitoneum&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a> In 1996&#44; Parodi successfully described this approach for pseudoaneurysms and other vascular traumas&#46;<a class="elsevierStyleCrossRef" href="#bib9">9</a> Alternative treatments&#44; such as pseudoaneurysm embolization&#44; have been described in selected cases&#46;<a class="elsevierStyleCrossRef" href="#bib10">10</a></p><p id="para110" class="elsevierStylePara elsevierViewall">In patients presenting with abdominal pain and a medical history of abdominal trauma that may have occurred many years before&#44; a high index of clinical suspicion is crucial for the diagnosis of abdominal aortic pseudoaneurysms&#44; particularly when symptoms include back pain or a pulsatile abdominal mass&#46; Imaging examinations should be performed promptly for a precise diagnosis&#44; and the treatment should not be delayed because of the high mortality associated with the spontaneous rupture of these lesions&#46;</p></span></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos