- Email: [email protected]
A Contained Ruptured Abdominal Aortic Aneurysm Presenting with Vertebral Erosion
Accepted Manuscript A contained ruptured abdominal aortic aneurysm presenting with vertebral erosion Yongqi Li, Lei Li, Dongming Zhang, Xiaomei Wang, Weidong Sun, Han Wang PII:
S0890-5096(17)30265-0
DOI:
10.1016/j.avsg.2016.09.025
Reference:
AVSG 3147
To appear in:
Annals of Vascular Surgery
Received Date: 14 April 2016 Revised Date:
7 September 2016
Accepted Date: 9 September 2016
Please cite this article as: Li Y, Li L, Zhang D, Wang X, Sun W, Wang H, A contained ruptured abdominal aortic aneurysm presenting with vertebral erosion, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.09.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
A contained ruptured abdominal aortic aneurysm presenting with vertebral erosion
2
Yongqi Li1,3, Lei Li1*, Dongming Zhang1, Xiaomei Wang2, Weidong Sun1, Han Wang1
3
1
4
University, Dalian, Liaoning Province, People's Republic of China.
5
2
6
Dalian, Liaoning Province, People's Republic of China.
7
3
8
Ibaraki ken, Japan
9
Running title: A CCR-AAA presenting with vertebral erosion
RI PT
Department of Vascular Surgery, The Second Affiliated Hospital of Dalian Medical
Department of Radiology, The Second Affiliated Hospital of Dalian Medical University,
M AN U
SC
Current address: Laboratory of Experimental Pathology, University of Tsukuba, Tsukuba shi,
*Corresponding author: Lei Li MD
11
The Second Affiliated Hospital of Dalian Medical University, 467 Zhongshan Road,
12
ShaheKou District, Dalian, Liaoning, People's Republic of China.
13
Email: [email protected]/ [email protected]
14
Phone: +88615541178098
15
Fax: +88684672130
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ACCEPTED MANUSCRIPT Abstract
18
Chronic contained rupture (CCR) of abdominal aortic aneurysm (AAA) with vertebral
19
erosion is a rare condition. Although it has been reported previously, it is still liable to be
20
misdiagnosed. We present a case of CCR of AAA with vertebral erosion. A brief analysis of
21
similar cases reported in the last five years is presented.
22
A 71-year-old male was admitted to our hospital because of severe prickling pain in his left
23
thigh. Computerized tomography angiography revealed an AAA which had caused erosion of
24
L3 vertebral body and the left psoas muscle. An aortotomy was performed and the excised
25
aortic aneurysm replaced with a Dacron graft. Postoperative CT angiography indicated a
26
normal aortic graft. The patient was discharged 13 days after the surgery. In conclusion: Pain
27
in lower back and leg could be associated with vertebral erosion caused by CCR of AAA.
28
Ultrasonography, CT or MRI of abdomen should be routinely performed in cases of lumbago
29
that have associated risk factors for AAA.
30
Keywords: abdominal aortic aneurysm, contained rupture, vertebral erosion.
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ACCEPTED MANUSCRIPT 1. Introduction
33
When blood leaking from the ruptured abdominal aortic aneurysm is confined to the
34
retroperitoneal cavity by the surrounding tissue, the hemodynamic parameters tend to remain
35
stable, and the condition is referred to as chronic contained rupture of abdominal aortic
36
aneurysm (CCR-AAA)[1]. CCR-AAA accounts for only 4% of all ruptured AAA[2].
37
Occurrence of spinal erosion due to CCR-AAA is even rarer[3]. However, similar to the one
38
without vertebral erosion, it is associated with a high risk of evolving into free rupture. Arici
39
et al. reported a mortality rate of 17%, although comorbidities may also have contributed to
40
the mortality at least in some of the cases[4]. In spite of the availability of contrast-enhanced
41
computed tomography (CT) and magnetic resonance imaging to facilitate the diagnosis,
42
manifestations of CCR-AAA with vertebral erosion remain ambiguous[5].
43
2. Case report
44
A 71-year-old male was admitted to the emergency department with complaints of severe
45
prickling pain in his left thigh since the last six days. The patient had a history of smoking for
46
more than 50 years (20 cigarettes per day). He was a known case of coronary heart disease,
47
and had undergone coronary stent implantation in the left anterior descending artery seven
48
years ago. His hemodynamic parameters were normal. Physical examination revealed a
49
pulsatile mass in the abdomen. Complete blood count showed slightly decreased red blood
50
cell count (3.34×1012/L) along with decreased hemoglobin (101 g/L), while the routine blood
51
biochemical parameters were normal.
52
CT scan of the abdomen suggested enlarged abnormal aorta, which prompted us to perform a
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3
ACCEPTED MANUSCRIPT computerized tomography angiography, and which revealed an abdominal aortic aneurysm
54
6.4 cm in diameter, and bilateral common iliac artery aneurysms. The aortic aneurysm had
55
caused erosion of the left psoas muscle and the anterior 30% of the L3 vertebral body (Figure
56
1 & 2). In addition, a small amount of contrast medium was observed in the hematoma
57
surrounding the aorta, which suggested leakage of blood from the abdominal aorta, which
58
was confined in the pseudoaneurysm. Based on the clinical features, laboratory results and
59
imaging findings, the patient was diagnosed as a case of CCR of AAA.
60
An open abdomen surgery was performed for the repair of the aortic aneurysm. After cross
61
clamping the abdominal aorta, aortotomy was performed. A defect in the posterior wall of
62
aorta along with perforation in the vertebral body, measuring 3 × 4 cm, was found. The
63
vertebral body was filled with bone wax and the excised aortic aneurysm replaced with an 8
64
mm × 16 mm Y-shaped Dacron graft. Pathological examination of the excised arterial wall
65
did not reveal any special findings. The patient developed acute left heart failure shortly after
66
the surgery, which was resolved with medication. Repeat CT angiography demonstrated a
67
normal aortic graft and no postoperative complications occurred (Figure 3). Thirteen days
68
after the surgery, the patient was discharged; pain in his left extremity was relieved.
69
3. Review of Literature and Discussion
70
Ever since the first case of CCR-AAA causing lumbar vertebral erosion was reported by Katz
71
et al[6] in 1962, less than 100 similar cases have been documented worldwide. A case of
72
CCR-AAA is liable to be mistaken for a vertebral or retroperitoneal tumor, psoas or spinal
73
abscess, spondylitis or osteoporosis, owing to its rarity, lack of typical manifestations,
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ACCEPTED MANUSCRIPT findings of vertebral erosion, and the presence of low density mass surrounding the
75
abdominal aorta in the retroperitoneal space on CT scan. In order to characterize the clinical
76
features of this disease, we searched the PubMed database for reports on CCR-AAA that
77
caused lumbar vertebral erosion, published since 2011. We retrieved 12 reports (Table 1). A
78
brief analysis of these cases along with findings of the present case report is presented.
79
The pathogenesis of AAA is still obscure. Smoking, old age, male gender, atherosclerotic
80
arterial disease, dyslipidemia, family history are common risk factors associated with
81
AAA[7]. In addition, infection and inflammation are also reported to be involved in its
82
pathogenesis[8]. Since our patient did not present with a fever, nor manifested any abnormal
83
biochemical or hematological parameters suggestive of infection and inflammation, the
84
possibility of infection and vasculitis was deemed highly unlikely Among the 12 cases
85
reported above, all were males except one. Average age of the patients was 62.25 years; 10
86
cases (83.3%) were > 50 years of age. Of these, four patients had a history of smoking,
87
dyslipidemia, hypertension, or diabetes. Two cases were diagnosed with Behcet’s disease, an
88
autoimmune disease which damages various organs, including vascular system[9, 10]. One
89
patient was a case of osteogenesis imperfecta who had a six-year-long history of back pain
90
[11]. One patient had a history of chronic renal failure and emphysema, and had undergone
91
coronary artery bypass grafting (CABG). This patient died of pneumonia during
92
treatment[12].
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Most patients complained of discomfort that ranged from weeks to months. The most
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common symptoms of CCR-AAA with vertebral erosion were lower back pain (N=10;
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83.3%), followed by leg pain or claudication (N=6; 50%), pulsatile mass (N=4; 33.3%),
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ACCEPTED MANUSCRIPT abdominal pain (N=1; 8.3%), shoulder pain (N=1; 8.3%), and hematemesis (N=1; 8.3%). One
97
patient who presented with sudden onset of hematemesis was found to have aortoenteric
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fistula, a rare complication of AAA[13].
99
Lower back pain is a symptom with low specificity, although it was the most common
100
symptom of CCR-AAA with vertebral erosion. In the U.S.A, lower back pain is the
101
fifth-leading cause of hospital admissions, and the third most common cause of surgical
102
procedures[14]. In order to make the right diagnosis of CCR-AAA with vertebral erosion, it is
103
strongly suggested that ultrasound scan, CT or MRI of abdomen be performed routinely in a
104
patient with risk factors associated with AAA and presenting with lumbago.
105
In the present case, the patient complained of severe prickling pain in the left thigh, which, in
106
all probability, was caused by compression of the left femoral nerve by the enlarged
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pseudoaneurysm. Femoral nerve arises from divisions of L2-L4 lumbar nerves and provides
108
sensory innervations over the front and inner sides of thigh. It descends through the psoas
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major muscle, and eventually runs into thigh. Although it was only six days since the advent
110
of the presenting symptom, it is possible that the CCR-AAA with eroded vertebrae had
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existed for a much longer time. Perhaps only when the CCR-AAA began to compress the left
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femoral nerve, did the pricking pain start.
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CCR-AAA may cause erosion of any lumbar vertebra. The most commonly involved
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vertebrae in previous reports were (in that order): L3 (N=10; 90.9%), L4 (N=6; 54.5%), and
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L2 (N=4; 36.4%). In the present case the enlarged pseudoaneurysm had eroded the anterior
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30% of the third lumbar vertebral body, and had formed a cavity measuring 3 cm × 4 cm in
117
size. The pathogenesis of vertebral erosion in CCR-AAA is not clear. Some researchers
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ACCEPTED MANUSCRIPT believe that repetitive beats from pulsating aorta and blood jet leads to the destruction of the
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vertebra, while others have attributed it to infection and/or inflammation[4]. However, no
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correlation has been reported between the diameter of CCR-AAA and vertebral erosion.
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There are two main surgical methods for treating CCR-AAA: open repair of the aortic
122
aneurysm and endovascular aneurysm repair (EVAR). The choice of surgical approach is
123
based on the parameters of the ruptured aneurysm, the patient’s general condition,
124
institutional capacity, and on surgeon’s preferences [7]. In the present case, we opted for open
125
abdomen repair instead of EVAR as the aneurysmal neck was not long enough to
126
accommodate a stent. The decision to perform surgical reconstruction of the eroded vertebrae
127
is a crucial consideration in these patients as well. The site and extent of the erosion, along
128
with the patient’s general condition are key factors that influence treatment strategy[15]. We
129
did not perform spinal fixation on the eroded vertebra immediately in the present case
130
because the patients’ spine was considered stable enough based on the three-column theory.
131
Follow-up examination also showed that the erosion did not affect his normal life.
132
4. Conclusion
133
CCR-AAA with vertebral erosion is a rare but potentially life threatening condition which
134
usually presents with pain in lower back and leg. The condition could be associated with
135
erosion of any lumbar vertebral body, but L3 and L4 vertebral bodies are most commonly
136
involved. It is strongly recommended that ultrasonography, CT or MRI of abdomen be
137
performed routinely in cases of lumbago who manifest risk factors for AAA.
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ACCEPTED MANUSCRIPT 139
Reference
140
1.
Sterpetti AV, Blair EA, Schultz RD, Feldhaus RJ, Cisternino S, Chasan P. Sealed rupture
142
of abdominal aortic aneurysms. J Vasc Surg. 1990;11(3):430-5.
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2.
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aortic aneurysm presenting as a back mass. J Thorac Imaging. 2006;21(3):219-21.
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3.
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mimicking infective spondylitis. Eur Spine J. 1996;5(2):128-30.
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4.
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with chronic rupture of infrarenal aortic aneurysm: case report and systematic review of the
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literature in the English language. Spine (Phila Pa 1976). 2012;37(26):E1665-71.
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5.
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1994;163(1):17-29.
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6.
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aneurysm: an unusual case. Can Med Assoc J. 1962;87:187-9.
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7.
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ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease
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(lower extremity, renal, mesenteric, and abdominal aortic): executive summary a
157
collaborative report from the American Association for Vascular Surgery/Society for Vascular
158
Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular
159
Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force
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on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of
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141
Bansal M, Bansal M, Thukral BB, Malik A. Contained rupture of a thoracoabdominal
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Grevitt MP, Fagg PS, Mulholland RC. Chronic contained rupture of an aortic aneurysm
Arici V, Rossi M, Bozzani A, Moia A, Odero A. Massive vertebral destruction associated
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Siegel CL, Cohan RH. CT of abdominal aortic aneurysms. AJR Am J Roentgenol.
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Katz SH, Harrison AW, Key JA. Vertebral erosion by an atherosclerotic lumbar aortic
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al.
8
ACCEPTED MANUSCRIPT Patients With Peripheral Arterial Disease) endorsed by the American Association of
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Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute;
163
Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease
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Foundation. J Am Coll Cardiol. 2006;47(6):1239-312.
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8.
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aortic aneurysm and inflammatory aortic aneurysm--in search of an optimal differential
167
diagnosis. J Cardiol. 2012;59(2):123-31.
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9.
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aortic aneurysm: an insidious eventuality causing vertebra destruction in Behcet's disease.
170
Acta Reumatol Port. 2014;39(2):193-4.
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10. Orucu M, Keles D, Peker E, Cakici M, Shimbori N, Erden I, et al. Abdominal aortic
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aneurysm causing lumbar vertebral erosion in Behcet's disease presenting by low back pain.
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Rheumatol Int. 2015;35(2):367-70.
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11. Davies H, Davie MW. An unusual cause of spinal bone loss detected by DXA scanning.
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Osteoporos Int. 2013;24(3):1125-6.
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12. Keller A. Chronic contained aortic rupture presenting as anterior thigh pain. BMJ Case
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Rep. 2012;2012.
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13. Yie K, Lee SJ, Ryu SM, Kim HR. Unknown etiology aortic aneurysm complicated with
179
multiple vertebral erosions and aortoenteric fistula. Surgery. 2011;150(1):137-8.
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14. Baliga S, Treon K, Craig NJ. Low Back Pain: Current Surgical Approaches. Asian Spine
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J. 2015;9(4):645-57.
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15. Jimenez Viseu Pinheiro JF, Blanco Blanco JF, Pescador Hernandez D, Garcia Garcia FJ.
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Ishizaka N, Sohmiya K, Miyamura M, Umeda T, Tsuji M, Katsumata T, et al. Infected
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Kara M, Hatipoglu C, Ekiz T, Ozcakar L. Chronic contained rupture of an abdominal
9
ACCEPTED MANUSCRIPT Vertebral destruction due to abdominal aortic aneurysm. Int J Surg Case Rep. 2015;6c:296-9.
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16. Alshafei A, Kamal D. Chronic Contained Abdominal Aortic Aneurysm Rupture
185
Mimicking Vertebral Spondylodiscitis: A Case Report. Ann Vasc Dis. 2015;8(2):113-5.
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17. Singla V, Virmani V, Modi M, Kalra N, Khandelwal N. Chronic rupture of abdominal
187
aortic aneurysm with vertebral erosion: an uncommon but important cause of back pain. Ann
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Vasc Surg. 2014;28(8):1931 e1-4.
189
18. Nakano S, Okauchi K, Tsushima Y. Chronic contained rupture of abdominal aortic
190
aneurysm (CCR-AAA) with massive vertebral bone erosion: computed tomography (CT),
191
magnetic resonance imaging (MRI) and fluorine-18-fluorodeoxyglucose positron emission
192
tomography (FDG-PET) findings. Jpn J Radiol. 2014;32(2):109-12.
193
19. Stefanczyk L, Elgalal M, Papiewski A, Szubert W, Szopinski P. Infectious or
194
noninfectious? Ruptured, thrombosed inflammatory aortic aneurysm with spondylolysis.
195
Cardiovasc Intervent Radiol. 2013;36(3):839-43.
196
20. Tsubota H, Nakamura T. Chronic contained rupture of an abdominal aortic aneurysm
197
manifesting as lower extremity neuropathy. J Vasc Surg. 2012;55(2):548.
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ACCEPTED MANUSCRIPT Figure legends
200
Figure 1: Horizontal plane of computerized tomography angiography showing eroded
201
vertebral body and left psoas muscle due to enlarged psudoaneurysm.
202
Figure 2: Sagittal plane of computerized tomography angiography showing the eroded third
203
lumbar vertebral body
204
Figure 3: Postoperative computerized tomography angiography of the abdominal aorta
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ACCEPTED MANUSCRIPT
Table 1: Basic demographic and clinical information of patients in 23 reports Main symptoms and
Treatment Treatment of Eroded
Diameter Previous
their duration and Sex
vertebrae of AAA
Low back pain, 63 M
claudication, pulsatile mass. 4m
Jimenez-Viseu Pinheiro et 75 F
Low back pain, pulsatile
L4
4 cm
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Alshafei et al. [16]
L2-L4 mass. 6m
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al. [15]
of AAA
spine
Smoking,
Open
No surgical
dyslipidemia,
Surgery
treatment
55 M
L3-L4
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pain. 2y
Smoking,
Discharged dyslipidemia
68 M
treatment
Stabilization
EVAR
No surgical
Behcet’s disease
Discharged treatment
Low back pain, Singla et al. [17]
No surgical Spinal
5 cm
5 cm
EVAR L3
5.5 cm
Discharged treatment
Low back pain, 38 M
Behcet’s disease Open L3
62 M
Low back and leg pain
No surgical
4 cm
claudication in right leg Nakano et al. [18]
No surgical
Diabetes
pulsatile mass. 4m
Kara et al. [9]
Discharged
hypertension
Shoulder pain, low back Örücü et al. [10]
Outcome
history
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(m =month; y= year)
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Age (y) Authors
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L4
Not 12
Discharged 6 years ago
surgery
treatment
Not described
Open
Lumbar
Discharged
ACCEPTED MANUSCRIPT
described
surgery
interbody
Acute ischemia of left leg, abdominal pain with Stefanczyk et al. [19]
59 M
L3-L4
73 M
Back pain. 6y
L2-L3
Low back pain. 6m
L2-L3
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Arici et al. [4]
68 M
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Davies et al. [11]
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region for weeks
No surgical
Not described
SC
radiation to the lumbar
9.5 cm
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fusion
Osteogenesis
Discharged EVAR
treatment
Not
Not described
14 cm
10.4 cm
Discharged imperfecta
described Open
Spinal
surgery
stabilization
Hypertension
Discharged
Chronic renal
No surgical No surgical
failure,
treatment
treatment
83 M
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Left anterolateral thigh Keller et al. [12]
L2-L3
5 cm
underwent
Death
and knee pain. 3d
Tsubota et al. [20]
60 M
CABG, emphysema
Right thigh and right knee L3-L4 13
11 cm
Not described
Open
No surgical
Discharged
ACCEPTED MANUSCRIPT
pain, low back pain,
surgery
treatment
Open
No surgical
surgery
treatment
Not
Not
hematemesis
described
described history
43 M
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CABG, Coronary artery bypass graft
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Sudden onset of
No positive
SC
Yie et al. [13]
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pulsatile mass. 2m
14
Discharged
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S0890-5096(17)30265-0
DOI:
10.1016/j.avsg.2016.09.025
Reference:
AVSG 3147
To appear in:
Annals of Vascular Surgery
Received Date: 14 April 2016 Revised Date:
7 September 2016
Accepted Date: 9 September 2016
Please cite this article as: Li Y, Li L, Zhang D, Wang X, Sun W, Wang H, A contained ruptured abdominal aortic aneurysm presenting with vertebral erosion, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.09.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
A contained ruptured abdominal aortic aneurysm presenting with vertebral erosion
2
Yongqi Li1,3, Lei Li1*, Dongming Zhang1, Xiaomei Wang2, Weidong Sun1, Han Wang1
3
1
4
University, Dalian, Liaoning Province, People's Republic of China.
5
2
6
Dalian, Liaoning Province, People's Republic of China.
7
3
8
Ibaraki ken, Japan
9
Running title: A CCR-AAA presenting with vertebral erosion
RI PT
Department of Vascular Surgery, The Second Affiliated Hospital of Dalian Medical
Department of Radiology, The Second Affiliated Hospital of Dalian Medical University,
M AN U
SC
Current address: Laboratory of Experimental Pathology, University of Tsukuba, Tsukuba shi,
*Corresponding author: Lei Li MD
11
The Second Affiliated Hospital of Dalian Medical University, 467 Zhongshan Road,
12
ShaheKou District, Dalian, Liaoning, People's Republic of China.
13
Email: [email protected]/ [email protected]
14
Phone: +88615541178098
15
Fax: +88684672130
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1
ACCEPTED MANUSCRIPT Abstract
18
Chronic contained rupture (CCR) of abdominal aortic aneurysm (AAA) with vertebral
19
erosion is a rare condition. Although it has been reported previously, it is still liable to be
20
misdiagnosed. We present a case of CCR of AAA with vertebral erosion. A brief analysis of
21
similar cases reported in the last five years is presented.
22
A 71-year-old male was admitted to our hospital because of severe prickling pain in his left
23
thigh. Computerized tomography angiography revealed an AAA which had caused erosion of
24
L3 vertebral body and the left psoas muscle. An aortotomy was performed and the excised
25
aortic aneurysm replaced with a Dacron graft. Postoperative CT angiography indicated a
26
normal aortic graft. The patient was discharged 13 days after the surgery. In conclusion: Pain
27
in lower back and leg could be associated with vertebral erosion caused by CCR of AAA.
28
Ultrasonography, CT or MRI of abdomen should be routinely performed in cases of lumbago
29
that have associated risk factors for AAA.
30
Keywords: abdominal aortic aneurysm, contained rupture, vertebral erosion.
SC
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2
ACCEPTED MANUSCRIPT 1. Introduction
33
When blood leaking from the ruptured abdominal aortic aneurysm is confined to the
34
retroperitoneal cavity by the surrounding tissue, the hemodynamic parameters tend to remain
35
stable, and the condition is referred to as chronic contained rupture of abdominal aortic
36
aneurysm (CCR-AAA)[1]. CCR-AAA accounts for only 4% of all ruptured AAA[2].
37
Occurrence of spinal erosion due to CCR-AAA is even rarer[3]. However, similar to the one
38
without vertebral erosion, it is associated with a high risk of evolving into free rupture. Arici
39
et al. reported a mortality rate of 17%, although comorbidities may also have contributed to
40
the mortality at least in some of the cases[4]. In spite of the availability of contrast-enhanced
41
computed tomography (CT) and magnetic resonance imaging to facilitate the diagnosis,
42
manifestations of CCR-AAA with vertebral erosion remain ambiguous[5].
43
2. Case report
44
A 71-year-old male was admitted to the emergency department with complaints of severe
45
prickling pain in his left thigh since the last six days. The patient had a history of smoking for
46
more than 50 years (20 cigarettes per day). He was a known case of coronary heart disease,
47
and had undergone coronary stent implantation in the left anterior descending artery seven
48
years ago. His hemodynamic parameters were normal. Physical examination revealed a
49
pulsatile mass in the abdomen. Complete blood count showed slightly decreased red blood
50
cell count (3.34×1012/L) along with decreased hemoglobin (101 g/L), while the routine blood
51
biochemical parameters were normal.
52
CT scan of the abdomen suggested enlarged abnormal aorta, which prompted us to perform a
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32
3
ACCEPTED MANUSCRIPT computerized tomography angiography, and which revealed an abdominal aortic aneurysm
54
6.4 cm in diameter, and bilateral common iliac artery aneurysms. The aortic aneurysm had
55
caused erosion of the left psoas muscle and the anterior 30% of the L3 vertebral body (Figure
56
1 & 2). In addition, a small amount of contrast medium was observed in the hematoma
57
surrounding the aorta, which suggested leakage of blood from the abdominal aorta, which
58
was confined in the pseudoaneurysm. Based on the clinical features, laboratory results and
59
imaging findings, the patient was diagnosed as a case of CCR of AAA.
60
An open abdomen surgery was performed for the repair of the aortic aneurysm. After cross
61
clamping the abdominal aorta, aortotomy was performed. A defect in the posterior wall of
62
aorta along with perforation in the vertebral body, measuring 3 × 4 cm, was found. The
63
vertebral body was filled with bone wax and the excised aortic aneurysm replaced with an 8
64
mm × 16 mm Y-shaped Dacron graft. Pathological examination of the excised arterial wall
65
did not reveal any special findings. The patient developed acute left heart failure shortly after
66
the surgery, which was resolved with medication. Repeat CT angiography demonstrated a
67
normal aortic graft and no postoperative complications occurred (Figure 3). Thirteen days
68
after the surgery, the patient was discharged; pain in his left extremity was relieved.
69
3. Review of Literature and Discussion
70
Ever since the first case of CCR-AAA causing lumbar vertebral erosion was reported by Katz
71
et al[6] in 1962, less than 100 similar cases have been documented worldwide. A case of
72
CCR-AAA is liable to be mistaken for a vertebral or retroperitoneal tumor, psoas or spinal
73
abscess, spondylitis or osteoporosis, owing to its rarity, lack of typical manifestations,
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75
abdominal aorta in the retroperitoneal space on CT scan. In order to characterize the clinical
76
features of this disease, we searched the PubMed database for reports on CCR-AAA that
77
caused lumbar vertebral erosion, published since 2011. We retrieved 12 reports (Table 1). A
78
brief analysis of these cases along with findings of the present case report is presented.
79
The pathogenesis of AAA is still obscure. Smoking, old age, male gender, atherosclerotic
80
arterial disease, dyslipidemia, family history are common risk factors associated with
81
AAA[7]. In addition, infection and inflammation are also reported to be involved in its
82
pathogenesis[8]. Since our patient did not present with a fever, nor manifested any abnormal
83
biochemical or hematological parameters suggestive of infection and inflammation, the
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possibility of infection and vasculitis was deemed highly unlikely Among the 12 cases
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reported above, all were males except one. Average age of the patients was 62.25 years; 10
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cases (83.3%) were > 50 years of age. Of these, four patients had a history of smoking,
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dyslipidemia, hypertension, or diabetes. Two cases were diagnosed with Behcet’s disease, an
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autoimmune disease which damages various organs, including vascular system[9, 10]. One
89
patient was a case of osteogenesis imperfecta who had a six-year-long history of back pain
90
[11]. One patient had a history of chronic renal failure and emphysema, and had undergone
91
coronary artery bypass grafting (CABG). This patient died of pneumonia during
92
treatment[12].
93
Most patients complained of discomfort that ranged from weeks to months. The most
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common symptoms of CCR-AAA with vertebral erosion were lower back pain (N=10;
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83.3%), followed by leg pain or claudication (N=6; 50%), pulsatile mass (N=4; 33.3%),
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patient who presented with sudden onset of hematemesis was found to have aortoenteric
98
fistula, a rare complication of AAA[13].
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Lower back pain is a symptom with low specificity, although it was the most common
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symptom of CCR-AAA with vertebral erosion. In the U.S.A, lower back pain is the
101
fifth-leading cause of hospital admissions, and the third most common cause of surgical
102
procedures[14]. In order to make the right diagnosis of CCR-AAA with vertebral erosion, it is
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strongly suggested that ultrasound scan, CT or MRI of abdomen be performed routinely in a
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patient with risk factors associated with AAA and presenting with lumbago.
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In the present case, the patient complained of severe prickling pain in the left thigh, which, in
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all probability, was caused by compression of the left femoral nerve by the enlarged
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pseudoaneurysm. Femoral nerve arises from divisions of L2-L4 lumbar nerves and provides
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sensory innervations over the front and inner sides of thigh. It descends through the psoas
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major muscle, and eventually runs into thigh. Although it was only six days since the advent
110
of the presenting symptom, it is possible that the CCR-AAA with eroded vertebrae had
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existed for a much longer time. Perhaps only when the CCR-AAA began to compress the left
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femoral nerve, did the pricking pain start.
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CCR-AAA may cause erosion of any lumbar vertebra. The most commonly involved
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vertebrae in previous reports were (in that order): L3 (N=10; 90.9%), L4 (N=6; 54.5%), and
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L2 (N=4; 36.4%). In the present case the enlarged pseudoaneurysm had eroded the anterior
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30% of the third lumbar vertebral body, and had formed a cavity measuring 3 cm × 4 cm in
117
size. The pathogenesis of vertebral erosion in CCR-AAA is not clear. Some researchers
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119
vertebra, while others have attributed it to infection and/or inflammation[4]. However, no
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correlation has been reported between the diameter of CCR-AAA and vertebral erosion.
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There are two main surgical methods for treating CCR-AAA: open repair of the aortic
122
aneurysm and endovascular aneurysm repair (EVAR). The choice of surgical approach is
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based on the parameters of the ruptured aneurysm, the patient’s general condition,
124
institutional capacity, and on surgeon’s preferences [7]. In the present case, we opted for open
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abdomen repair instead of EVAR as the aneurysmal neck was not long enough to
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accommodate a stent. The decision to perform surgical reconstruction of the eroded vertebrae
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is a crucial consideration in these patients as well. The site and extent of the erosion, along
128
with the patient’s general condition are key factors that influence treatment strategy[15]. We
129
did not perform spinal fixation on the eroded vertebra immediately in the present case
130
because the patients’ spine was considered stable enough based on the three-column theory.
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Follow-up examination also showed that the erosion did not affect his normal life.
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4. Conclusion
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CCR-AAA with vertebral erosion is a rare but potentially life threatening condition which
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usually presents with pain in lower back and leg. The condition could be associated with
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erosion of any lumbar vertebral body, but L3 and L4 vertebral bodies are most commonly
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involved. It is strongly recommended that ultrasonography, CT or MRI of abdomen be
137
performed routinely in cases of lumbago who manifest risk factors for AAA.
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Reference
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1.
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(lower extremity, renal, mesenteric, and abdominal aortic): executive summary a
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collaborative report from the American Association for Vascular Surgery/Society for Vascular
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Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular
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Bansal M, Bansal M, Thukral BB, Malik A. Contained rupture of a thoracoabdominal
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Grevitt MP, Fagg PS, Mulholland RC. Chronic contained rupture of an aortic aneurysm
Arici V, Rossi M, Bozzani A, Moia A, Odero A. Massive vertebral destruction associated
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aortic aneurysm and inflammatory aortic aneurysm--in search of an optimal differential
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aortic aneurysm: an insidious eventuality causing vertebra destruction in Behcet's disease.
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10. Orucu M, Keles D, Peker E, Cakici M, Shimbori N, Erden I, et al. Abdominal aortic
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11. Davies H, Davie MW. An unusual cause of spinal bone loss detected by DXA scanning.
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12. Keller A. Chronic contained aortic rupture presenting as anterior thigh pain. BMJ Case
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13. Yie K, Lee SJ, Ryu SM, Kim HR. Unknown etiology aortic aneurysm complicated with
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14. Baliga S, Treon K, Craig NJ. Low Back Pain: Current Surgical Approaches. Asian Spine
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16. Alshafei A, Kamal D. Chronic Contained Abdominal Aortic Aneurysm Rupture
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Mimicking Vertebral Spondylodiscitis: A Case Report. Ann Vasc Dis. 2015;8(2):113-5.
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18. Nakano S, Okauchi K, Tsushima Y. Chronic contained rupture of abdominal aortic
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19. Stefanczyk L, Elgalal M, Papiewski A, Szubert W, Szopinski P. Infectious or
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20. Tsubota H, Nakamura T. Chronic contained rupture of an abdominal aortic aneurysm
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Figure 1: Horizontal plane of computerized tomography angiography showing eroded
201
vertebral body and left psoas muscle due to enlarged psudoaneurysm.
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Figure 2: Sagittal plane of computerized tomography angiography showing the eroded third
203
lumbar vertebral body
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Figure 3: Postoperative computerized tomography angiography of the abdominal aorta
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Table 1: Basic demographic and clinical information of patients in 23 reports Main symptoms and
Treatment Treatment of Eroded
Diameter Previous
their duration and Sex
vertebrae of AAA
Low back pain, 63 M
claudication, pulsatile mass. 4m
Jimenez-Viseu Pinheiro et 75 F
Low back pain, pulsatile
L4
4 cm
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Alshafei et al. [16]
L2-L4 mass. 6m
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al. [15]
of AAA
spine
Smoking,
Open
No surgical
dyslipidemia,
Surgery
treatment
55 M
L3-L4
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pain. 2y
Smoking,
Discharged dyslipidemia
68 M
treatment
Stabilization
EVAR
No surgical
Behcet’s disease
Discharged treatment
Low back pain, Singla et al. [17]
No surgical Spinal
5 cm
5 cm
EVAR L3
5.5 cm
Discharged treatment
Low back pain, 38 M
Behcet’s disease Open L3
62 M
Low back and leg pain
No surgical
4 cm
claudication in right leg Nakano et al. [18]
No surgical
Diabetes
pulsatile mass. 4m
Kara et al. [9]
Discharged
hypertension
Shoulder pain, low back Örücü et al. [10]
Outcome
history
SC
(m =month; y= year)
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Age (y) Authors
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L4
Not 12
Discharged 6 years ago
surgery
treatment
Not described
Open
Lumbar
Discharged
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described
surgery
interbody
Acute ischemia of left leg, abdominal pain with Stefanczyk et al. [19]
59 M
L3-L4
73 M
Back pain. 6y
L2-L3
Low back pain. 6m
L2-L3
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68 M
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Davies et al. [11]
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region for weeks
No surgical
Not described
SC
radiation to the lumbar
9.5 cm
RI PT
fusion
Osteogenesis
Discharged EVAR
treatment
Not
Not described
14 cm
10.4 cm
Discharged imperfecta
described Open
Spinal
surgery
stabilization
Hypertension
Discharged
Chronic renal
No surgical No surgical
failure,
treatment
treatment
83 M
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Left anterolateral thigh Keller et al. [12]
L2-L3
5 cm
underwent
Death
and knee pain. 3d
Tsubota et al. [20]
60 M
CABG, emphysema
Right thigh and right knee L3-L4 13
11 cm
Not described
Open
No surgical
Discharged
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pain, low back pain,
surgery
treatment
Open
No surgical
surgery
treatment
Not
Not
hematemesis
described
described history
43 M
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CABG, Coronary artery bypass graft
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Sudden onset of
No positive
SC
Yie et al. [13]
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pulsatile mass. 2m
14
Discharged
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