79 years old female, DM,HTN,known IHD and had PCI 5 years back. Echo shows EF 45% with no significant wall motion abnormalities and moderate mitral regurgitation
Presented with sudden chest pain, haemoptysis and drop of Hb, BP 100/60mm Hg
CTA scan done by medical team included
What would be your assessment approach?
What would be your choice of modality for investigation?
What would be the plan of management?
What would be your follow up / surveillance plan?
Please support your answers with guidelines/evidence”
This is a ruptured TAAA, ABC, permissive hypotension, Emergency TEVAR
This is a ruptured TAAA, ABC, permissive hypotension, Emergency TEVAR,
Q1,
First I will start with vital signs , blood pressure and heart rate,
Urine output and kidney and liver functions
According o the CT patient has ruptured thoracic aortic aneurysm
The main goal is to keep the patient vitally stable and with complete vascular and neurological assessment.
Q2.
Multislice Ct angiography of the whole aorta is the investigation of choice
Q3.
CT angiography is essential to make sure the anatomy is appropriate and if so Urgent TEVAR would be the first option for intervention ( ESVS recommendation 23 class I )
Planning of the anatomy, landing zone, and aortic coverage and possibility of covering subclavian artery
If extensive thoracic aorta coverage is planned (>200 mm ) prophylactic cerebrospinal fluid drainage should be considered in endovascular thoracic aorta repair to protect against spinal cord ischemia(ESVS recommendation 10 class IIa )
Q4.
Follow up of vital signs, blood pressure, neurological assessment, cardiac condition and urine output
Follow up with CT angiography after 6 months then on yearly basis
Thanks a lot, good answer
Just one point to discuss, do you think it is better to have surveillance before 6 months. And through the clinical picture and CTA , is there any other complicated nature of the aneurysm that may need another modality of surveillance to avoid mid to long term complication
the aneurysm may be of inflammatory type increasing the risk for graft infection so lab tests, CRP, ESR and blood culture are important
FDG-PET CT has more role in detection of infection and extent of it.
Thanks for your answer
As well there is findings suggestive of aorta bronchial fistula that my superimpose graft infection and my necessitate close follow up with PET/WCC scans and possible long term antibiotics regimen
Patient have ruptured thoracic aneurysm
**Vital signs maintaining systolic blood pressure 70-90/ airway and oxygen sat %.
neurological / vascular examination
Full lab / urine output.
**using CTA proper sizing for the thoracic aorta and landing zones (prox and distal) with suitable anatomy prepare for TEVAR. ESVS IIa
Spinal cord protection by csf drainge mybe needed if extensive coverage needed ESVS IIa
** follow up post operative
Neurological examination/ full lab urine output
After one month repeat CTA if normal repeat after one year
If ct detect abnormality repeat after 6m (SVS 2018)
Very good
From history and CTA do you suspect any complicated nature of that rupture ? and what would be the risk of graft infection?
Yes heamoptysis hb drop suspected aorto- bronchial fistula with high risk of graft infection.
**TEVAR and Staged or concomitant coverage of of the graft with muscle or pericardium. With broad spectrum antibiotics to cover first 24h i.v ESVS (Class I)
***Follow up with CTA if suspected endograft infection class I (perigraft gas or fluid ) And FDG-PET ct is to confirm and increase accuracy and accuracy extension Of infection (class I)
Blood culture maybe used as minor criteria MAGIC classification for graft infection ESVS .
Very good
thanks
Q1
The goal is to keep stability of pt as possible as we can by permissive hypotension whic is method to save the LOC and myocardium by keeping Bp 70 to 90 and HR .
prepare the pt for urgent intervension prepare blood and OT as pt has rDTAA with high mortality
Insertion of peripheral lines and possiboility Central line kidney function urine output PT INR ECG
Call for anesthiea cardiology and ICU team
Q2.CTA
MRA
Transesophageal echo
Q3.
Emergency TEVAR if anatomy is suitable class 1 level b
Q4.
Follow up post op to detect pssibility of early complication so, central and peripheral neurological assessment to exclude complication stroke SCI, peripheral vascular system, kidney fonction, bowel ischemia
Vital signs urine output and ABG
Survillance by CTA
Very good
What would be (from clinical scenario and CTA ) other possible complications
What would be your surveillance plan based on the answer of the previous question please
What would be your assessment approach?
patient should be resuscitated immediately by 2 wide pore cannulas urinary catheter for urine output blood transfusion to correct Hb drop.
it should be arranged for urgent Endovascular repair even there’s possibility of aorto-pulmonary fistula, it should be treated by endovascular repair followed by open repair of the fistula to prevent stent infection
What would be your choice of modality for investigation?
since the patient already made CTA no other investigation is needed and the CTA should be processed for the choice of the suitable graft
What would be the plan of management?
Even if Patients treated as emergency cases experience a greater 30-day mortality rate compared to patients treated electively. Emergent TEVAR is the treatment of choice.
What would be your follow up / surveillance plan?
it should followed up by CTA to detect any type of endoleak , broad spectrum Antibiotics to prevent any graft infection, CBC to detect any Hb drop, and scheduled for another open repair of the fistula if needed .
Reference
Management of Descending Thoracic Aorta Diseases Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)
.
Thanks, very good. Would you consider any other imaging to investigate possible future graft infection?
FDG-PET/CT is of choice to detect possible graft infection along with WBC count and blood culture
Source
Diagnostic Imaging in Vascular Graft Infection: A Systematic Review and Meta-Analysis
Eline I. Reinders Folmer a, Gerdine C.I. Von Meijenfeldt a, Maarten J. Van der Laan a, Andor W.J.M. Glaudemans b, Riemer H.J.A. Slart b c, Ben R. Saleem a, Clark J. Zeebregts a
Very good, thanks