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Erosion of lumbar vertebral bodies from a chronic contained rupture of an abdominal aortic pseudoaneurysm
Erosion of lumbar vertebral bodies from a chronic contained rupture of an abdominal aortic pseudoaneurysm W. Andrew Oldenburg, MD, and Tariq Almerey, MD, Jacksonville, Fla
Chronic contained rupture (CCR) of an abdominal aortic aneurysm is a rare occurrence. Erosion of the vertebral bodies in association with a CCR of an abdominal aortic aneurysm is rarer and creates a diagnostic dilemma. One needs to exclude fractures, neoplasms, osteoporosis, and infection as possible other causes. We describe a patient with a previous aortobilateral external iliac graft that was complicated by a pseudoaneurysm with a CCR at the proximal anastomosis of the graft associated with vertebral body erosion. Extra-anatomic bypass and removal of the previous aortobilateral external iliac graft was performed. (J Vasc Surg Cases 2016;2:197-9.)
Long-term complications from open repair of an abdominal aortic aneurysm (AAA) include graft infection, graft limb thrombosis, aortoenteric fistula or erosions, ureteral obstruction, and pseudoaneurysm formation at the proximal and distal anastomotic sites. Erosion of vertebral bodies secondary to AAA is extremely rare1,2 and usually associated with infection. We report a case of vertebral body erosion secondary to a sterile pseudoaneurysm of the proximal aorta with a chronic contained rupture (CCR) following a previous open repair of an AAA. Consent for publication was obtained by the patient’s medical power of attorney.
CASE REPORT An 80-year-old white man with a history of smoking, hyperten-
(CT)-guided needle aspiration for culture was negative. Pathologic examination demonstrated organized hematoma. The patient initially declined surgery, but 5 months later, he returned with increasing back pain and an increase in the aneurysm sac to 9.5 cm in diameter. On physical examination, his abdomen was soft and nontender with some fullness in the left lower quadrant. He had þ2 femoral and popliteal pulses with absent pedal pulses bilaterally. The patient was afebrile with no leukocytosis and an elevated sedimentation rate. Repeated CT-guided biopsy of the necrotic vertebral body demonstrated no evidence of tumor, and cultures (including for acid-fast bacilli) were negative. After consenting to surgery and because of the concern for indolent infection, the patient underwent a staged operative
sion, and dyslipidemia presented with an asymptomatic 8.6-cm
approach consisting of an axillobifemoral bypass graft using 8-mm externally supported Propaten (W. L. Gore & Associates,
juxtarenal pseudoaneurysm with evidence of a contained
Flagstaff, Ariz) polytetrafluoroethylene grafts followed 1 day later
rupture with erosion into the second and third lumbar vertebrae
by removal of the previous aortic graft. His second surgery was
(L2 and L3) and psoas muscle.
performed through a left retroperitoneal approach; the supra-
Eight years earlier, the patient had an AneuRx (Medtronic, Santa
celiac aorta was cross-clamped after heparin, mannitol, and
Rosa, Calif) endoluminal aortic stent graft repair of an AAA. Four
furosemide were administered, and the previous aortobiexternal
years after his primary operation, the patient developed a symptomatic type I endoleak treated with removal of the endoluminal
iliac graft was removed. The proximal infrarenal aorta was closed
aortic stent graft, ligation of both common iliac arteries, and inser-
just below the renal arteries with horizontal and vertical mattress sutures of 2-0 Prolene. Because the distal limbs of
tion of an aortobilateral external iliac bypass graft. Both of these
the aortobiexternal iliac graft were well incorporated, the distal
operations were performed at outside facilities.
limbs were ligated and divided proximally to the distal external
On presentation to our institution, investigations demon-
iliac anastomoses to preserve hypogastric blood flow. The lum-
strated no leukocytosis. His sedimentation rate was elevated
bar vertebral bodies were extensively débrided with an anterior
at 38 (normal, 0-22). The findings on an indium-labeled
L2-L3 diskectomy and left-sided L2-L3 decompressive foraminot-
white blood cell scan were normal. Computed tomography
omy performed by neurosurgery. The aortic stump was wrapped
From the Department of Vascular Surgery, Mayo Clinic Jacksonville.
with an omental flap. At the end of the procedure, the patient’s right foot was mottled and without pedal Doppler signals. For
Author conflict of interest: none. Correspondence: Tariq Almerey, MD, 4500 San Pablo Rd, Jacksonville, FL (e-mail: [email protected]).
this reason, the right common femoral anastomosis was opened, and an attempt at a thrombectomy of the right lower
The editors and reviewers of this article have no relevant financial relationships to
extremity was performed. No clot was retrieved. A right lower
disclose per the Journal policy that requires reviewers to decline review of any
extremity arteriogram was obtained and demonstrated that
manuscript for which they may have a conflict of interest.
the axillobifemoral bypass and superficial femoral, profunda,
2468-4287 Ó 2016 The Author(s). Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.jvscit.2016.08.006
popliteal, and proximal tibial arteries were all widely patent. All tibial arteries were occluded in the right distal calf. Chronic nonreconstructible distal occlusive disease was suspected, and the surgery was terminated to rewarm the patient. 197
198
Oldenburg and Almerey
Journal of Vascular Surgery Cases and Innovative Techniques December 2016
Fig 1. Computed tomography (CT) scan showing pseudoaneurysm at the proximal junction of the aortic graft, with erosion of L2.
Fig 2. Magnetic resonance image showing L2-L3 erosion.
His postoperative course was complicated by acute renal failure requiring temporary hemodialysis. All cultures obtained at the time of the surgery, including bacterial, fungal and acidfast bacillary, remained negative. The patient was discharged on postoperative day 27. The patient never regained Doppler signals in the foot and developed dry gangrene of the distal right foot that prompted a below-knee amputation 45 days later. Six months later, the patient was ambulating with a below-knee prosthesis and had full recovery of his renal function. Follow-up CT scan of his aorta demonstrated no signs of infection and stabilization of his spine. The patient died 24 months later of unrelated causes and without signs of infection.
DISCUSSION A retroperitoneal mass in connection with an AAA or aortic pseudoaneurysm presents a diagnostic dilemma. Causes include a ruptured AAA, infection, malignant disease, and CCR. First described by Szilagyi et al in 1961 and further defined by Alshafei and Kamal in 2015,3,4 a CCR of an AAA has been defined by a hemodynamically stable patient with varying degrees of chronic symptoms and the presence of a retroperitoneal hematoma on CT or magnetic resonance imaging that is confirmed on pathologic examination. Whereas AAA is a common disorder, it has been estimated that CCR of an AAA occurs in only 4% of all ruptured aortic aneurysms.4 First described by Halliday and al-Kutoubi in 1996, the CT finding of a “draped aorta” over the vertebral bodies is highly suggestive of a CCR of the aorta.5 Our patient did not have the classic findings of a draped aorta, but this may have been due to the fact that he had had previous aortic surgery with scarring of the retroperitoneal planes (Figs 1-3).
Fig 3. Computed tomography (CT) scan showing pseudoaneurysm invading L2-L3.
Long-term complications from AAA repair occur in roughly 9% of patients, with pseudoaneurysm formation at an anastomotic site occurring in 3% and only onethird occurring at the proximal aortic anastomosis.6 Traditionally, proximal aortic pseudoaneurysms have been associated with infection, such as syphilitic aortitis or mycotic aneurysms. Vertebral body erosion is usually caused by osteoporosis or fractures, neoplasms, or infection. On review of the literature, vertebral body erosion by a CCR of an AAA without evidence of infection has been reported rarely, and only four previous cases had a CCR in association with an aortic pseudoaneurysm.1,2,7,8 Vertebral
Oldenburg and Almerey
Journal of Vascular Surgery Cases and Innovative Techniques
199
Volume 2, Number 4
body erosion is thought to be secondary to the pounding nature of the aneurysm, which results in ischemia of the vertebral bone.9 Vertebral erosion caused by aneurysms is usually smooth, in contrast to that caused by infection, in which the margins of the lytic process are irregular and poorly defined.10 A CCR of an AAA or aortic graft may have an infectious source, although frequently this is not conclusively determined until the surgery has been performed and all cultures are negative. In our case, we were concerned for an indolent infection, which was why we performed an axillobifemoral bypass and excised the aneurysm and old graft with oversewing of the aortic stump. Other options would include anatomic reconstruction with a rifampin-soaked or silver-impregnated graft or homograft. Despite being a rare condition, CCR of an AAA or aortic graft causing erosion of the vertebral bodies should be considered in the differential diagnosis of low back pain and sciatica in patients with a history of aortic disease and a large retroperitoneal mass contiguous with an aortic aneurysm or pseudoaneurysm eroding into the vertebral bodies.
2.
3.
4.
5. 6.
7.
8.
9.
10.
REFERENCES 1. Kapoor V, Kanal E, Fukui MB. Vertebral mass resulting from a chronic-contained rupture of an abdominal aortic aneurysm repair graft [erratum in: AJNR Am J
Neuroradiol 2002;23:156]. AJNR Am J Neuroradiol 2001;22:1775-7. Diekerhof CH, Reedt Dortland RW, Oner FC, Verbout AJ. Severe erosion of lumbar vertebral body because of abdominal aortic false aneurysm: report of 2 cases. Spine 2002;27:E382-4. Szilagyi DE, Smith RF, Macksood AJ, Whitcomb G. Expanding and ruptured abdominal aortic aneurysms. Problems of diagnosis and treatment. Arch Surg 1961;83:395-408. Alshafei A, Kamal D. Chronic contained abdominal aortic aneurysm rupture mimicking vertebral spondylodiscitis: a case report. Ann Vasc Dis 2015;8:113-5. Halliday KE, al-Kutoubi A. Draped aorta: CT sign of contained leak of aortic aneurysms. Radiology 1996;199:41-3. Hallett JW Jr, Marshall DM, Petterson TM, Gray DT, Bower TC, Cherry KJ Jr, et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg 1997;25:277-84. Prete PE, Thorne RP, Robinson CA. Low-back pain and vertebral erosion due to aortic anastomotic false aneurysm, with documentation by computerized tomography. J Bone Joint Surg Am 1980;62:126-8. Usselman JA, Vint VC, Kleiman SA. CT diagnosis of aortic pseudoaneurysm causing vertebral erosion. AJR Am J Roentgenol 1979;133:1177-9. Farhan-Alanie OM, Ahmed Z, Stuart W. Vertebral erosion resulting from a ‘non-ruptured’ abdominal aortic aneurysm: case report and literature review. Scott Med J 2012;57:182. Jones CS, Reilly MK, Dalsing MC, Glover JL. Chronic contained rupture of abdominal aortic aneurysms. Arch Surg 1986;121: 542-6.
Submitted Jun 28, 2016; accepted Aug 25, 2016.
Chronic contained rupture (CCR) of an abdominal aortic aneurysm is a rare occurrence. Erosion of the vertebral bodies in association with a CCR of an abdominal aortic aneurysm is rarer and creates a diagnostic dilemma. One needs to exclude fractures, neoplasms, osteoporosis, and infection as possible other causes. We describe a patient with a previous aortobilateral external iliac graft that was complicated by a pseudoaneurysm with a CCR at the proximal anastomosis of the graft associated with vertebral body erosion. Extra-anatomic bypass and removal of the previous aortobilateral external iliac graft was performed. (J Vasc Surg Cases 2016;2:197-9.)
Long-term complications from open repair of an abdominal aortic aneurysm (AAA) include graft infection, graft limb thrombosis, aortoenteric fistula or erosions, ureteral obstruction, and pseudoaneurysm formation at the proximal and distal anastomotic sites. Erosion of vertebral bodies secondary to AAA is extremely rare1,2 and usually associated with infection. We report a case of vertebral body erosion secondary to a sterile pseudoaneurysm of the proximal aorta with a chronic contained rupture (CCR) following a previous open repair of an AAA. Consent for publication was obtained by the patient’s medical power of attorney.
CASE REPORT An 80-year-old white man with a history of smoking, hyperten-
(CT)-guided needle aspiration for culture was negative. Pathologic examination demonstrated organized hematoma. The patient initially declined surgery, but 5 months later, he returned with increasing back pain and an increase in the aneurysm sac to 9.5 cm in diameter. On physical examination, his abdomen was soft and nontender with some fullness in the left lower quadrant. He had þ2 femoral and popliteal pulses with absent pedal pulses bilaterally. The patient was afebrile with no leukocytosis and an elevated sedimentation rate. Repeated CT-guided biopsy of the necrotic vertebral body demonstrated no evidence of tumor, and cultures (including for acid-fast bacilli) were negative. After consenting to surgery and because of the concern for indolent infection, the patient underwent a staged operative
sion, and dyslipidemia presented with an asymptomatic 8.6-cm
approach consisting of an axillobifemoral bypass graft using 8-mm externally supported Propaten (W. L. Gore & Associates,
juxtarenal pseudoaneurysm with evidence of a contained
Flagstaff, Ariz) polytetrafluoroethylene grafts followed 1 day later
rupture with erosion into the second and third lumbar vertebrae
by removal of the previous aortic graft. His second surgery was
(L2 and L3) and psoas muscle.
performed through a left retroperitoneal approach; the supra-
Eight years earlier, the patient had an AneuRx (Medtronic, Santa
celiac aorta was cross-clamped after heparin, mannitol, and
Rosa, Calif) endoluminal aortic stent graft repair of an AAA. Four
furosemide were administered, and the previous aortobiexternal
years after his primary operation, the patient developed a symptomatic type I endoleak treated with removal of the endoluminal
iliac graft was removed. The proximal infrarenal aorta was closed
aortic stent graft, ligation of both common iliac arteries, and inser-
just below the renal arteries with horizontal and vertical mattress sutures of 2-0 Prolene. Because the distal limbs of
tion of an aortobilateral external iliac bypass graft. Both of these
the aortobiexternal iliac graft were well incorporated, the distal
operations were performed at outside facilities.
limbs were ligated and divided proximally to the distal external
On presentation to our institution, investigations demon-
iliac anastomoses to preserve hypogastric blood flow. The lum-
strated no leukocytosis. His sedimentation rate was elevated
bar vertebral bodies were extensively débrided with an anterior
at 38 (normal, 0-22). The findings on an indium-labeled
L2-L3 diskectomy and left-sided L2-L3 decompressive foraminot-
white blood cell scan were normal. Computed tomography
omy performed by neurosurgery. The aortic stump was wrapped
From the Department of Vascular Surgery, Mayo Clinic Jacksonville.
with an omental flap. At the end of the procedure, the patient’s right foot was mottled and without pedal Doppler signals. For
Author conflict of interest: none. Correspondence: Tariq Almerey, MD, 4500 San Pablo Rd, Jacksonville, FL (e-mail: [email protected]).
this reason, the right common femoral anastomosis was opened, and an attempt at a thrombectomy of the right lower
The editors and reviewers of this article have no relevant financial relationships to
extremity was performed. No clot was retrieved. A right lower
disclose per the Journal policy that requires reviewers to decline review of any
extremity arteriogram was obtained and demonstrated that
manuscript for which they may have a conflict of interest.
the axillobifemoral bypass and superficial femoral, profunda,
2468-4287 Ó 2016 The Author(s). Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.jvscit.2016.08.006
popliteal, and proximal tibial arteries were all widely patent. All tibial arteries were occluded in the right distal calf. Chronic nonreconstructible distal occlusive disease was suspected, and the surgery was terminated to rewarm the patient. 197
198
Oldenburg and Almerey
Journal of Vascular Surgery Cases and Innovative Techniques December 2016
Fig 1. Computed tomography (CT) scan showing pseudoaneurysm at the proximal junction of the aortic graft, with erosion of L2.
Fig 2. Magnetic resonance image showing L2-L3 erosion.
His postoperative course was complicated by acute renal failure requiring temporary hemodialysis. All cultures obtained at the time of the surgery, including bacterial, fungal and acidfast bacillary, remained negative. The patient was discharged on postoperative day 27. The patient never regained Doppler signals in the foot and developed dry gangrene of the distal right foot that prompted a below-knee amputation 45 days later. Six months later, the patient was ambulating with a below-knee prosthesis and had full recovery of his renal function. Follow-up CT scan of his aorta demonstrated no signs of infection and stabilization of his spine. The patient died 24 months later of unrelated causes and without signs of infection.
DISCUSSION A retroperitoneal mass in connection with an AAA or aortic pseudoaneurysm presents a diagnostic dilemma. Causes include a ruptured AAA, infection, malignant disease, and CCR. First described by Szilagyi et al in 1961 and further defined by Alshafei and Kamal in 2015,3,4 a CCR of an AAA has been defined by a hemodynamically stable patient with varying degrees of chronic symptoms and the presence of a retroperitoneal hematoma on CT or magnetic resonance imaging that is confirmed on pathologic examination. Whereas AAA is a common disorder, it has been estimated that CCR of an AAA occurs in only 4% of all ruptured aortic aneurysms.4 First described by Halliday and al-Kutoubi in 1996, the CT finding of a “draped aorta” over the vertebral bodies is highly suggestive of a CCR of the aorta.5 Our patient did not have the classic findings of a draped aorta, but this may have been due to the fact that he had had previous aortic surgery with scarring of the retroperitoneal planes (Figs 1-3).
Fig 3. Computed tomography (CT) scan showing pseudoaneurysm invading L2-L3.
Long-term complications from AAA repair occur in roughly 9% of patients, with pseudoaneurysm formation at an anastomotic site occurring in 3% and only onethird occurring at the proximal aortic anastomosis.6 Traditionally, proximal aortic pseudoaneurysms have been associated with infection, such as syphilitic aortitis or mycotic aneurysms. Vertebral body erosion is usually caused by osteoporosis or fractures, neoplasms, or infection. On review of the literature, vertebral body erosion by a CCR of an AAA without evidence of infection has been reported rarely, and only four previous cases had a CCR in association with an aortic pseudoaneurysm.1,2,7,8 Vertebral
Oldenburg and Almerey
Journal of Vascular Surgery Cases and Innovative Techniques
199
Volume 2, Number 4
body erosion is thought to be secondary to the pounding nature of the aneurysm, which results in ischemia of the vertebral bone.9 Vertebral erosion caused by aneurysms is usually smooth, in contrast to that caused by infection, in which the margins of the lytic process are irregular and poorly defined.10 A CCR of an AAA or aortic graft may have an infectious source, although frequently this is not conclusively determined until the surgery has been performed and all cultures are negative. In our case, we were concerned for an indolent infection, which was why we performed an axillobifemoral bypass and excised the aneurysm and old graft with oversewing of the aortic stump. Other options would include anatomic reconstruction with a rifampin-soaked or silver-impregnated graft or homograft. Despite being a rare condition, CCR of an AAA or aortic graft causing erosion of the vertebral bodies should be considered in the differential diagnosis of low back pain and sciatica in patients with a history of aortic disease and a large retroperitoneal mass contiguous with an aortic aneurysm or pseudoaneurysm eroding into the vertebral bodies.
2.
3.
4.
5. 6.
7.
8.
9.
10.
REFERENCES 1. Kapoor V, Kanal E, Fukui MB. Vertebral mass resulting from a chronic-contained rupture of an abdominal aortic aneurysm repair graft [erratum in: AJNR Am J
Neuroradiol 2002;23:156]. AJNR Am J Neuroradiol 2001;22:1775-7. Diekerhof CH, Reedt Dortland RW, Oner FC, Verbout AJ. Severe erosion of lumbar vertebral body because of abdominal aortic false aneurysm: report of 2 cases. Spine 2002;27:E382-4. Szilagyi DE, Smith RF, Macksood AJ, Whitcomb G. Expanding and ruptured abdominal aortic aneurysms. Problems of diagnosis and treatment. Arch Surg 1961;83:395-408. Alshafei A, Kamal D. Chronic contained abdominal aortic aneurysm rupture mimicking vertebral spondylodiscitis: a case report. Ann Vasc Dis 2015;8:113-5. Halliday KE, al-Kutoubi A. Draped aorta: CT sign of contained leak of aortic aneurysms. Radiology 1996;199:41-3. Hallett JW Jr, Marshall DM, Petterson TM, Gray DT, Bower TC, Cherry KJ Jr, et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg 1997;25:277-84. Prete PE, Thorne RP, Robinson CA. Low-back pain and vertebral erosion due to aortic anastomotic false aneurysm, with documentation by computerized tomography. J Bone Joint Surg Am 1980;62:126-8. Usselman JA, Vint VC, Kleiman SA. CT diagnosis of aortic pseudoaneurysm causing vertebral erosion. AJR Am J Roentgenol 1979;133:1177-9. Farhan-Alanie OM, Ahmed Z, Stuart W. Vertebral erosion resulting from a ‘non-ruptured’ abdominal aortic aneurysm: case report and literature review. Scott Med J 2012;57:182. Jones CS, Reilly MK, Dalsing MC, Glover JL. Chronic contained rupture of abdominal aortic aneurysms. Arch Surg 1986;121: 542-6.
Submitted Jun 28, 2016; accepted Aug 25, 2016.