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A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneurysm
YAJEM-158598; No of Pages 3 American Journal of Emergency Medicine xxx (xxxx) xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneurysm Jason R. West, MD a,⁎, Christopher S. Keller, BS b, Joel Lombardi, MD a,c a b c
Lincoln Medical Center, Department of Emergency Medicine, Bronx, NY, USA St. George's School of Medicine, West Indies, Grenada Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA, USA
a r t i c l e
i n f o
Article history: Received 9 October 2019 Accepted 13 November 2019 Available online xxxx Keywords: Limb ischemia EVAR Emergency
a b s t r a c t Background: Thrombosis of an endovascular aortic repair (EVAR) is a devastating complication of a common surgical procedure that can lead to serious morbidity and mortality if not promptly recognized. This is the first case report of an EVAR graft thrombosis in the emergency medicine literature. Case report: We present a case of a patient with lower extremity paraplegia secondary to thrombosis of an EVAR graft who presented to the emergency room with acute stroke-like symptoms after a recent EVAR procedure. Endovascular repair of abdominal aortic aneurisms is becoming more frequent, and an increased number of patients with recent abdominal aortic aneurism repair by endovascular grafts will be evaluated by emergency physicians in the future. Emergency physicians should be aware that signs of limb ischemia, which may masquerade as acute ischemic stroke-like symptoms, is one of the more serious complications that can occur with abdominal aortic vascular grafts. Among patients with lower extremity neurological deficits in the recent setting of EVAR presenting to an emergency department, there should be a high degree of suspicion for EVAR graft thrombosis, which can be diagnosed via the gold standard of CT angiography or ultrasonography. Prompt vascular surgery consultation is essential to minimize permanent disability. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Endovascular aortic repair (EVAR) has been used increasingly for abdominal aortic aneurysm repair since the 1990s [1]. EVAR is an attractive alternative to open repair across all ages, largely due to decreased peri-operative morbidity and mortality when compared with open surgery [2]. However, this procedure has considerable risk of complications, including endovascular leaks, graft infection, limb ischemia due to graft thrombosis, and spinal cord injury. Despite EVAR having an early survival benefit compared to open repair, patients undergoing EVAR are recommended to undergo continual surveillance for later complications [1,2]. 2. Case report A prehospital emergency service provided advanced notification that a patient with acute stroke-like symptoms, including unilateral lower extremity paralysis, was en-route to our emergency department (ED). Upon initial ED assessment, we found the 79 year-old patient to be alert and with the following vital signs: Temperature 97°F, BP 102/ 80, respiratory rate of 21, and SpO2 99% on room air. The patient ⁎ Corresponding author at: Lincoln Medical Center, Bronx, NY, USA. E-mail address: [email protected] (J.R. West).
reported lower extremity weakness just prior to falling to the ground 1 h before ED arrival. The patient was triaged as having stroke-like symptoms and underwent an initial examination for having a potential ischemic stroke to our ED, which is an advanced certified primary stroke center. He was found to have intact cranial nerves and no neurological deficits of the upper extremities. The left lower extremity had no visible motor movement and absent sensation to light touch and painful stimuli. The right leg showed visible movement and response to painful stimulation. Bilateral healing inguinal incisions covered with sterile tape strips were noted, yet the patient could not recall the reason for these recent surgical incisions. Both lower extremities were warm; and there was no edema, erythema, pallor, or mottling of either lower extremity. The patient received a National Institute of Health Stroke Scale of 10 upon initial ED evaluation. Though the patient was triaged as a potential acute ischemic stroke, chest and pelvis radiographs were performed with concern for possible traumatic injury due to this patients’ fall from standing. No abnormalities were identified on these radiographs. The patient was expediently sent for computed tomography (CT) scans without contrast of the brain and lumbar spine in order to evaluate both acute stroke-like symptoms and potential trauma to the lumbar spine. The brain CT showed no acute findings, and the lumbar spine CT showed no lumbar spine fracture. While the patient was still on the CT table, we viewed the images and noticed signs of an abdominal aortic graft. Without
https://doi.org/10.1016/j.ajem.2019.11.021 0735-6757/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: J.R. West, C.S. Keller and J. Lombardi, A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneu..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.11.021
2
J.R. West et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
removing the patient from the CT table, a CT angiography scan of the aorta was ordered. This study identified the patient was status-post endovascular repair of an abdominal aortic aneurysm with complete thrombosis of the graft distal to the origin of the renal arteries. The images (Figs. 1 and 2), show the sagittal (Fig. 1) and axial (Fig. 2) CT angiography images of a thrombosis within the patient's EVAR graft. We immediately consulted a local vascular surgery center, and we heparinized the patient according to their recommendations in order to prevent
further acute EVAR graft thrombosis. During the patient’s care at the receiving center, he underwent a successful axillobifemoral bypass. 3. Discussion Recognizing acute aortic emergencies is a well-established concept in emergency medicine (EM). However, literature to help EM clinicians recognize the complications of EVAR thrombosis is not robust. We were
Fig. 1. Sagittal computed tomography image of showing thrombosis of the EVAR graft. White arrow points to EVAR graft thrombosis.
Please cite this article as: J.R. West, C.S. Keller and J. Lombardi, A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneu..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.11.021
J.R. West et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
3
Fig. 2. Axial computed tomography image showing thrombosis of the EVAR graft. White arrow points to EVAR graft thrombosis.
unable to find any previous case reports of limb ischemia after EVAR due to graft thrombosis within the emergency medicine literature. Ischemic complications after EVAR have been suggested to occur in 4–9% of patients, and lower limb ischemia is one of the more common ischemic complications [3,4]. Most of these cases are definitively treated by catheter directed thrombolysis [5], mechanical thrombectomy, or bypass surgery [6]. The patient’s advanced age was a risk factor for EVAR thrombosis [7]. Additional variables that could have helped predict the patient’s graft thrombosis include the EVAR graft configuration (aortouni-iliac) and graft material (polyester fabric) [7]. There is a deficit in the literature suggesting immediate ED interventions after identifying an EVAR graft thrombosis other than to obtain immediate surgical consultation. In this case we consulted vascular surgeons within our hospital network and heparinzed the patient according to their recommendations prior to transfer. Although the gold standard for diagnosing an EVAR graft complication is CT angiography; another promising tool for emergency providers is sonography, though this has only been studies using formal, non-bedside, sonographic studies [8].
References [1] Slama R, Long B, Koyfman A. The emergency medicine approach to abdominal vascular graft complications. Am J Emerg Med 2016;34:2014–7. [2] Patel R, Sweeting MJ, Powell JT, et al. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet 2016;388:2366–74. [3] Maldonado TS, Rockman CB, Riles E, et al. Ischemic complications after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2004:703–10. [4] van Zeggeren L, Bastos Goncalves F, van Herwaarden JA, et al. Incidence and treatment results of Endurant endograft occlusion. J Vasc Surg 2013;57:1246–54. [5] Waiting J, Dias A, Patel T, et al. Successful thrombolysis of a late acute thrombotic occlusion of an aortic prosthesis after endovascular aneurysm repair. Ann Vasc Surg 2014;28:1791. [6] Daye D, Walker TG. Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management. Cardiovasc Diagn Ther 2018;8: S138–56. [7] Oliveira NF, Bastos Gonçalves FM, Hoeks SE, et al. Clinical outcome and morphologic determinants of mural thrombus in abdominal aortic endografts. J Vasc Surg 2015; 61:1391–8. [8] Mazzaccaro D, Farina A, Petsos K, et al. The role of duplex ultrasound in detecting graft thrombosis and endoleak after endovascular aortic repair for abdominal aneurysm. Ann Vasc Surg 2018;52:22–9.
Please cite this article as: J.R. West, C.S. Keller and J. Lombardi, A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneu..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.11.021
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneurysm Jason R. West, MD a,⁎, Christopher S. Keller, BS b, Joel Lombardi, MD a,c a b c
Lincoln Medical Center, Department of Emergency Medicine, Bronx, NY, USA St. George's School of Medicine, West Indies, Grenada Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA, USA
a r t i c l e
i n f o
Article history: Received 9 October 2019 Accepted 13 November 2019 Available online xxxx Keywords: Limb ischemia EVAR Emergency
a b s t r a c t Background: Thrombosis of an endovascular aortic repair (EVAR) is a devastating complication of a common surgical procedure that can lead to serious morbidity and mortality if not promptly recognized. This is the first case report of an EVAR graft thrombosis in the emergency medicine literature. Case report: We present a case of a patient with lower extremity paraplegia secondary to thrombosis of an EVAR graft who presented to the emergency room with acute stroke-like symptoms after a recent EVAR procedure. Endovascular repair of abdominal aortic aneurisms is becoming more frequent, and an increased number of patients with recent abdominal aortic aneurism repair by endovascular grafts will be evaluated by emergency physicians in the future. Emergency physicians should be aware that signs of limb ischemia, which may masquerade as acute ischemic stroke-like symptoms, is one of the more serious complications that can occur with abdominal aortic vascular grafts. Among patients with lower extremity neurological deficits in the recent setting of EVAR presenting to an emergency department, there should be a high degree of suspicion for EVAR graft thrombosis, which can be diagnosed via the gold standard of CT angiography or ultrasonography. Prompt vascular surgery consultation is essential to minimize permanent disability. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Endovascular aortic repair (EVAR) has been used increasingly for abdominal aortic aneurysm repair since the 1990s [1]. EVAR is an attractive alternative to open repair across all ages, largely due to decreased peri-operative morbidity and mortality when compared with open surgery [2]. However, this procedure has considerable risk of complications, including endovascular leaks, graft infection, limb ischemia due to graft thrombosis, and spinal cord injury. Despite EVAR having an early survival benefit compared to open repair, patients undergoing EVAR are recommended to undergo continual surveillance for later complications [1,2]. 2. Case report A prehospital emergency service provided advanced notification that a patient with acute stroke-like symptoms, including unilateral lower extremity paralysis, was en-route to our emergency department (ED). Upon initial ED assessment, we found the 79 year-old patient to be alert and with the following vital signs: Temperature 97°F, BP 102/ 80, respiratory rate of 21, and SpO2 99% on room air. The patient ⁎ Corresponding author at: Lincoln Medical Center, Bronx, NY, USA. E-mail address: [email protected] (J.R. West).
reported lower extremity weakness just prior to falling to the ground 1 h before ED arrival. The patient was triaged as having stroke-like symptoms and underwent an initial examination for having a potential ischemic stroke to our ED, which is an advanced certified primary stroke center. He was found to have intact cranial nerves and no neurological deficits of the upper extremities. The left lower extremity had no visible motor movement and absent sensation to light touch and painful stimuli. The right leg showed visible movement and response to painful stimulation. Bilateral healing inguinal incisions covered with sterile tape strips were noted, yet the patient could not recall the reason for these recent surgical incisions. Both lower extremities were warm; and there was no edema, erythema, pallor, or mottling of either lower extremity. The patient received a National Institute of Health Stroke Scale of 10 upon initial ED evaluation. Though the patient was triaged as a potential acute ischemic stroke, chest and pelvis radiographs were performed with concern for possible traumatic injury due to this patients’ fall from standing. No abnormalities were identified on these radiographs. The patient was expediently sent for computed tomography (CT) scans without contrast of the brain and lumbar spine in order to evaluate both acute stroke-like symptoms and potential trauma to the lumbar spine. The brain CT showed no acute findings, and the lumbar spine CT showed no lumbar spine fracture. While the patient was still on the CT table, we viewed the images and noticed signs of an abdominal aortic graft. Without
https://doi.org/10.1016/j.ajem.2019.11.021 0735-6757/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: J.R. West, C.S. Keller and J. Lombardi, A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneu..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.11.021
2
J.R. West et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
removing the patient from the CT table, a CT angiography scan of the aorta was ordered. This study identified the patient was status-post endovascular repair of an abdominal aortic aneurysm with complete thrombosis of the graft distal to the origin of the renal arteries. The images (Figs. 1 and 2), show the sagittal (Fig. 1) and axial (Fig. 2) CT angiography images of a thrombosis within the patient's EVAR graft. We immediately consulted a local vascular surgery center, and we heparinized the patient according to their recommendations in order to prevent
further acute EVAR graft thrombosis. During the patient’s care at the receiving center, he underwent a successful axillobifemoral bypass. 3. Discussion Recognizing acute aortic emergencies is a well-established concept in emergency medicine (EM). However, literature to help EM clinicians recognize the complications of EVAR thrombosis is not robust. We were
Fig. 1. Sagittal computed tomography image of showing thrombosis of the EVAR graft. White arrow points to EVAR graft thrombosis.
Please cite this article as: J.R. West, C.S. Keller and J. Lombardi, A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneu..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.11.021
J.R. West et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
3
Fig. 2. Axial computed tomography image showing thrombosis of the EVAR graft. White arrow points to EVAR graft thrombosis.
unable to find any previous case reports of limb ischemia after EVAR due to graft thrombosis within the emergency medicine literature. Ischemic complications after EVAR have been suggested to occur in 4–9% of patients, and lower limb ischemia is one of the more common ischemic complications [3,4]. Most of these cases are definitively treated by catheter directed thrombolysis [5], mechanical thrombectomy, or bypass surgery [6]. The patient’s advanced age was a risk factor for EVAR thrombosis [7]. Additional variables that could have helped predict the patient’s graft thrombosis include the EVAR graft configuration (aortouni-iliac) and graft material (polyester fabric) [7]. There is a deficit in the literature suggesting immediate ED interventions after identifying an EVAR graft thrombosis other than to obtain immediate surgical consultation. In this case we consulted vascular surgeons within our hospital network and heparinzed the patient according to their recommendations prior to transfer. Although the gold standard for diagnosing an EVAR graft complication is CT angiography; another promising tool for emergency providers is sonography, though this has only been studies using formal, non-bedside, sonographic studies [8].
References [1] Slama R, Long B, Koyfman A. The emergency medicine approach to abdominal vascular graft complications. Am J Emerg Med 2016;34:2014–7. [2] Patel R, Sweeting MJ, Powell JT, et al. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet 2016;388:2366–74. [3] Maldonado TS, Rockman CB, Riles E, et al. Ischemic complications after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2004:703–10. [4] van Zeggeren L, Bastos Goncalves F, van Herwaarden JA, et al. Incidence and treatment results of Endurant endograft occlusion. J Vasc Surg 2013;57:1246–54. [5] Waiting J, Dias A, Patel T, et al. Successful thrombolysis of a late acute thrombotic occlusion of an aortic prosthesis after endovascular aneurysm repair. Ann Vasc Surg 2014;28:1791. [6] Daye D, Walker TG. Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management. Cardiovasc Diagn Ther 2018;8: S138–56. [7] Oliveira NF, Bastos Gonçalves FM, Hoeks SE, et al. Clinical outcome and morphologic determinants of mural thrombus in abdominal aortic endografts. J Vasc Surg 2015; 61:1391–8. [8] Mazzaccaro D, Farina A, Petsos K, et al. The role of duplex ultrasound in detecting graft thrombosis and endoleak after endovascular aortic repair for abdominal aneurysm. Ann Vasc Surg 2018;52:22–9.
Please cite this article as: J.R. West, C.S. Keller and J. Lombardi, A patient with lower extremity weakness after recent endovascular repair of an abdominal aortic aneu..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.11.021