A 61-year-old male patient with a history of suspended alcoholism and perforated gastric peptic ulcer suture at 50 years of age.
She reported a 4-month history of progressive dorsolumbar pain, fever and weight loss, accompanied by hematuria in the last weeks.
She was hospitalized with a diagnosis of acute pyelonephritis receiving empirical antibiotic treatment while waiting for a negative urocultive result.
The fever appeared despite antibiotic treatment with progressive increase in back pain, to the point of being intractable with usual analgesics.
Computed axial tomography (CAT) of the abdomen and pelvis revealed spondylitis with destruction of vertebral bodies of L1 and L2 in relation to a large pseudoaneurysm at the posterior surface of the aorta.
A possible infectious etiology of both pseudoaneurysm and spondylitis was assumed, hemocultives were taken and broad-spectrum antibiotic treatment was initiated.
1.
Given the location of the lesion, imminent rupture clinic and its high surgical risk, we evaluated the possibility of endovascular repair, limited by the need for occlusion of the superior mesenteric artery and pseudoaneurysm of the compromised area.
It was decided to perform a hybrid approach to the lesion, by means of revascularization circulation prior to installation of a straight endoprosthesis at the level of the visceral aorta in order to cover the segment of the compromised aorta and exclude the lesion
In the first time via midline laparotomy, a superior mesenteric iliac bypass was performed with saphenous vein ligand proximal mesenteric artery, evolving without evidence of ischemia month in the immediate postoperative period.
In a second time, 48 hours after the first intervention, angiography was performed to identify the origin of the pseudoaneurysm, the trunk, the renal arteries, and patency of the iliac-celomic bridge.
Then, under local anesthesia, the left common femoral artery was approached, where the extension of the visceral aorta vascular endoprosthesis of the abdominal aorta Powerlink® (Endologix®, California), which was programmed to exclude the aneurysm.
Balloon prosthesis was expanded CODA (CC®, Australia), and control angiography confirmed the exclusion of pseudoaneurysm and absence of endoleaks.
1.
Immediately, the patient reported no pain relief without intraoperative analgesia.
She had no evidence of vascular insufficiency month but systemic inflammatory response associated with acute renal and hepatic failure. She was managed in the ICU with complete recovery 72 h after the procedure.
Blood cultures were positive for multi-resistant Staphylococcus aureus; vancomycin was administered for 21 days until inflammatory parameters returned to normal.
Tomographic follow-up at one month confirmed the exclusion of the pseudoaneurysm, with no evidence of visceral ischemia attributable to occlusion of the celiac axis and revascularization of the trunk permeable.
At one year of follow-up, the patient is self-reliant and walking, without antibiotic therapy and without clinical or laboratory evidence of infection, which have been performed monthly.
Tomographic follow-up one year after surgery showed no endoleaks and the iliomesenteric bypass was patent.
