Contained rupture of the suprarenal John D. Nora, M.D., and Larry H. Hollier, M.D., Rochester, Minn. aorta A contained rupture of the aorta is a rare event; however, this has been recognized with increased frequency in the abdominal aorta. There have previously been two reports of the containment of rupture of the suprarenal aorta. We report two additional cases of contained rupture of the suprarenal aorta, one caused by a penetrating atherosclerotic ulcer, the other from a ruptured aneurysm. Surgical treatment was successful in both patients. (J VAsc SuRG 1987;5:651-4.) A chronic contained rupture of the aorta is a rare event. There are only a few case reports of this phe- nomenon, and there are only two previous reports of a contained rupture of the suprarenal aorta, xa We report two cases; one of a contained rupture of a suprarenal aneurysm and the other of a contained rupture of the suprarenal aorta resulting from a pen- etrating atherosclerotic ulcer. CASE REPORTS Case 1. A 56-year-old white man was referred to us with complaints of low back pain, which during the 6 weeks just before admission was becoming worse and more difficult to control with analgesics. An extensive evaluation in his home community, including x-ray films of the spine, upper gastrointestinal tract studies, barium enema, and ab- dominal C'T scanning showed no abnormalities. He de- scribed the pain as being sharp and radiating from the back around the flanks to the anterior abdomen. His medical history was significant for hypertension and tobacco abuse. Physical examination showed that the patient was not obese and had no palpable abdominal masses. He had de- creased femoral, popliteal, and pedal pulses. A repeat CT scan of the abdomen displayed a soft tissue mass contiguous with the posterior aorta for a distance of 6 cm in the retroaortic space, ending 2 cm above the renal arteries. The CT scan was interpreted as being suggestive of a contained aortic perforation (Fig. 1). An angiogram showed a pen- etrating ulcer with a contained rupture of the aorta at the level ofT-12 located posteriorly just above the level of the celiac axis origin (Fig. 2). At operation, a large aortic perforation was seen ex- tending into the retroaortic space, which was contained by thick fibrous tissue and the crura. A tube graft was placed from the distal thoracic aorta to the middle of the abdom- inal aorta, incorporating the celiac, superior mesenteric, and both renal arteries as part of a cuff in continuity with From the Department of Surgery (Dr. Nora) and the Section of Vascular Surgery (Dr. Hollier), Mayo Clinic and Mayo Foun- dation. Reprint requests: Larry H. HolLier,M.D., Mayo Clinic, 200 First St., S.W., Rochester, MN 55905. the distal anastomosis. The operative course was compli- cated by thrombosis of the right femoral artery, which was treated by an immediate thrombectomy. Pathologic examination of the resected perforation re- vealed a healing intimal ulcer and an apparent complete transmural aortic perforation occurring within an ather- oma. There was granulation tissue at the site of the per- foration, suggesting that the rupture was old, as well as an abundance of polymorphgtihclear leukocytes. Microorgan- isms were not seen, despite special stains, and all cultures of the specimen were negative. The patient did well post- operatively and was dismissed on the twelfth postoperative day. He continued to do well one year after operation. COMMENT: The cause of the contained rupture in this case was a penetrating athemmatous ulcer. As noted by Gore and Hirst a this is a rare cause of dissection or per- foration and usually occurs in the descending thoracic aorta. Stanson et al.4 have also reviewed this topic. Case 2. A 74-year-old white man with a known ab- dominal aneurysm since June 1982 was referred to the Mayo Clinic in June 1985 for complaints of increasing back and flank pain, which had become incapacitating. At the time of diagnosis of the aneurysm, an operation was not advised because the patient was considered to be in the high-risk category. The patient's medical history was significant for coronary artery disease, hypertension, chronic obstructive pulmonary disease, obesity, and to- bacco abuse. Physical examination indicated obesity, no palpable ab- dominal masses, decreased femoral pulses, and no palpable popliteal or pedal pulses. A preoperative CT scan showed a large fusiform, saccular aneurysm of the abdominal aorta, beginning at the diaphragmatic hiatus and ending just proximal to the aortic bifurcation. The aneurysm was de- scribed as having a peculiar nature, and a large portion of it was located posteriorly and was thought to represent a contained rupture (Fig. 3). At operation, a large pseudoaneurysm was identified involving the abdominal aorta from the diaphragm down to the level of the left renal vein. The aorta had a posterior rupture at the level of the celiac axis, but this rupture had been contained within the crura of the diaphragm and the retroperitoneal tissue. A woven Dacron graft was sutured to the distal thoracic aorta, and a cuff of the aorta con- 651
Transcript
Contained rupture of the suprarenal J o h n D. N o r a , M . D . , and L a r r y H . Ho l l i e r , M . D . , Rochester, Minn.
aorta
A contained rupture o f the aorta is a rare event; however, this has been recognized with increased frequency in the abdominal aorta. There have previously been two reports o f the containment o f rupture o f the suprarenal aorta. We report two additional cases o f contained rupture o f the suprarenal aorta, one caused by a penetrating atherosclerotic ulcer, the other from a ruptured aneurysm. Surgical treatment was successful in both patients. (J VAsc SuRG 1987;5:651-4.)
A chronic conta ined rupture o f the aorta is a rare event. There are only a few case reports o f this phe- nomenon , and there are only two previous reports o f a conta ined rupture o f the suprarenal aorta, xa W e repor t two cases; one o f a contained rupture o f a suprarenal aneurysm and the o ther o f a contained rupture o f the suprarenal aorta result ing f rom a pen- etrat ing atherosclerotic ulcer.
CASE REPORTS
Case 1. A 56-year-old white man was referred to us with complaints of low back pain, which during the 6 weeks just before admission was becoming worse and more difficult to control with analgesics. An extensive evaluation in his home community, including x-ray films of the spine, upper gastrointestinal tract studies, barium enema, and ab- dominal C'T scanning showed no abnormalities. He de- scribed the pain as being sharp and radiating from the back around the flanks to the anterior abdomen. His medical history was significant for hypertension and tobacco abuse.
Physical examination showed that the patient was not obese and had no palpable abdominal masses. He had de- creased femoral, popliteal, and pedal pulses. A repeat CT scan of the abdomen displayed a soft tissue mass contiguous with the posterior aorta for a distance of 6 cm in the retroaortic space, ending 2 cm above the renal arteries. The CT scan was interpreted as being suggestive of a contained aortic perforation (Fig. 1). An angiogram showed a pen- etrating ulcer with a contained rupture of the aorta at the level ofT-12 located posteriorly just above the level of the celiac axis origin (Fig. 2).
At operation, a large aortic perforation was seen ex- tending into the retroaortic space, which was contained by thick fibrous tissue and the crura. A tube graft was placed from the distal thoracic aorta to the middle of the abdom- inal aorta, incorporating the celiac, superior mesenteric, and both renal arteries as part of a cuff in continuity with
From the Department of Surgery (Dr. Nora) and the Section of Vascular Surgery (Dr. Hollier), Mayo Clinic and Mayo Foun- dation.
Reprint requests: Larry H. HolLier, M.D., Mayo Clinic, 200 First St., S.W., Rochester, MN 55905.
the distal anastomosis. The operative course was compli- cated by thrombosis of the right femoral artery, which was treated by an immediate thrombectomy.
Pathologic examination of the resected perforation re- vealed a healing intimal ulcer and an apparent complete transmural aortic perforation occurring within an ather- oma. There was granulation tissue at the site of the per- foration, suggesting that the rupture was old, as well as an abundance of polymorphgtihclear leukocytes. Microorgan- isms were not seen, despite special stains, and all cultures of the specimen were negative. The patient did well post- operatively and was dismissed on the twelfth postoperative day. He continued to do well one year after operation.
COMMENT: The cause of the contained rupture in this case was a penetrating athemmatous ulcer. As noted by Gore and Hirst a this is a rare cause of dissection or per- foration and usually occurs in the descending thoracic aorta. Stanson et al.4 have also reviewed this topic.
Case 2. A 74-year-old white man with a known ab- dominal aneurysm since June 1982 was referred to the Mayo Clinic in June 1985 for complaints of increasing back and flank pain, which had become incapacitating. At the time of diagnosis of the aneurysm, an operation was not advised because the patient was considered to be in the high-risk category. The patient's medical history was significant for coronary artery disease, hypertension, chronic obstructive pulmonary disease, obesity, and to- bacco abuse.
Physical examination indicated obesity, no palpable ab- dominal masses, decreased femoral pulses, and no palpable popliteal or pedal pulses. A preoperative CT scan showed a large fusiform, saccular aneurysm of the abdominal aorta, beginning at the diaphragmatic hiatus and ending just proximal to the aortic bifurcation. The aneurysm was de- scribed as having a peculiar nature, and a large portion of it was located posteriorly and was thought to represent a contained rupture (Fig. 3).
At operation, a large pseudoaneurysm was identified involving the abdominal aorta from the diaphragm down to the level of the left renal vein. The aorta had a posterior rupture at the level of the celiac axis, but this rupture had been contained within the crura of the diaphragm and the retroperitoneal tissue. A woven Dacron graft was sutured to the distal thoracic aorta, and a cuff of the aorta con-
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Fig. 1. CT scan of suprarenalaorta in case 1. CT scan demonstrates contained rupture of atherosclerotic ulcer (arrow).
taining the orifices of the celiac, superior mesenteric, and both renal arteries was reimplanted, the distal end of the graft being sutured to the distal abdominal aorta just prox- imal to the bifurcation. The patient was dismissed on the twelfth postoperative day. He continued to do well almost one year after operation.
DISCUSSION
Rupture of the aorta is usually a catastrophic event. However, evidence is accumulating that there is a subset of patients who are able to contain a rupture of the aorta. Darling s accumulated evidence in an autopsy series suggesting that in a subgroup of patients rupture of the infrarenal aorta can be con- tained and the patient can survive as long as 6 weeks, although death eventually occurred. Likewise, Szi- lagyi, Macksood, and Whitcomb 6 and Stoney and Wylie 7 in their review of ruptured aneurysms noted a subgroup of patients in whom aortic ruptures were contained for a variable period of time. Diagnosis of a contained rupture of the aorta can be difficult. An acute rupture can be diagnosed by the triad of pain, pulsatile mass, and hypotension. A chronic contained rupture usually manifests itself as pain, as displayed in our two patients. However, a contained rupture can also have several other manifestations at presen- tation. Reports in the literature document contained ruptures that have mimicked femoral neuropathy, radicular compression syndrome, obstructive jaun-
Fig. 2. Aortogram of case 1. Angiogram of contained rup- ture of atherosclerotic ulcer at the level of the celiac axis.
dice, or a symptomatic inguinal hernia, s-~2 Szilagyi, EUiott, and Smith 2 described a group of patients who had contained ruptures and presented a septic picture with anemia at admission. The radiologic diagnosis of a contained rupture can be difficult because it is the diagnosis of a retroperitoneal process. Conven- tional radiographic methods, when used to docu- ment retroperitoneal hemorrhage, rely greatly on inferential signs and lack both sensitivity and speci- ficity. Plain abdominal films may demonstrate ob- scuration of a psoas margin, but slight rotation or minimal spinal scoliosis can cause a similar roent- genographic appearance; in about 25% of normal persons, there is an unequal definition of the psoas borders. Other indirect findings, such as a soft tissue mass, intestinal ileus, and displacement or indenta- tion of neighboring organs (kidney, ureter, stomach, small intestine, or colon) may be visible on plain or contrast films. 13 As described in our case reports, standard radiologic methods were of no value. It has been shown that the CT scan is helpful in recognizing retroperitoneal hemorrhage13,14; we fotmd that the CT scan was diagnostic in this situation.
Containment of the rupture of the aorta is a func- tion of its surrounding tissue. In the case of the su- prarenal aorta it is the retroperitoneal tissue that must
Volume 5 Number 4 April 1987 Contained rupture of the suprarenal aorta 653
Fig. 3. CT scans of thoracoabdominal aneurysm show contained rupture of suprarenal an- eurysm. A, Aneurysm located at the level of the celiac axis; contained rupture tracking inferiorly (arrows) (B-D).
provide this capability. The ability of a patient to survive a rupture into the retroperitoneal space is a 1¢, nction of the resistance of the retroperitoneal tissue to dissection, thereby resulting in tamponade of the hemorrhage. Fitzgerald, Stillman, and Powers ~s in attempting to show that the size of the retroperito- neal hematoma has prognostic significance in the re- pair of a ruptured aneurysm aptly demonstrated that the retroperitoneal tissues did vary in ability to con- tain the hematoma. The hematoma may be contained because the rupture can occur into different retro- peritoneal compartments and the ability of these compartments to resist dissection may vary according to which retroperitoneal space is entered. In a review of cases of contained rupture of the intra-abdominal aorta and a review of the literature, Clayton, Walsh, and Brewer a noted that rupture of the aorta conld be contained by the perirenal or posterior pararenal (or both) space.
In our two cases, the ruptures were contained in the superior retroperitoneal space. This space is ceph- alad to the renal arteries, and its surrounding fascia is composed of elements from which the diaphrag- matic crura are derived. A description of the anatomy of this region was accurately described by Low 16 in 1907. The origin of the crura blends with the anterior
longitudinal ligament of the vertebral column and surrounds the suprarenal aorta laterally as it forms the aortic hiatus anteriorly at the level ofT-12. Low '6 described a fibromuscular bundle originating from the right crus and running inferiorly anterior to the aorta, enclosing the celiac axis and superior mesen- teric artery and finally attaching itself to the posterior aspect of the duodenum near the duodenal-jejunal flexure, that is, the ligament of Treitz.
We report herein two cases of contained rupture of the suprarenal aorta. Although several reports have appeared of containment of rupture of the infrarenal abdominal aorta, we have found only two previous reports of containment of a rupture of the suprarenal aorta. ',2 The diagnosis was achieved readily by use of the CT scan. Rupture of the suprarenal aorta was contained by the superior retroperitoneal space. Ap- propriate treatment for this condition is surgical cor- rection. The experiences reported by Darling s and Szilagyi et al. 2'6 seem to indicate that a chronic con- tained rupture is still at high risk for free rupture. Other reports have suggested that patients with a contained rupture of the abdominal aorta who are in stable condition can benefit from appropriate pre- operative preparation and urgent or elective rather than emergent operationY ,'" Similarly, our patients
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with a contained rupture of the suprarenal aorta had appropriate preoperative preparation before rupture repair with successful results.
REFERENCES
1. Clayton MJ, Walsh JW, Brewer WH. Contained rupture of abdominal aortic aneurysms: sonographic and CT diagnosis. AJR 1982;138:154-6.
2. Szilagyi DE, Elliott JP, Smith RF. Ruptured abdominal an- eurysms simulating sepsis. Arch Surg 1965;91:263-75.
3. Gore I, Hirst AE Jr. Dissecting aneurysm of the aorta. Car- diovasc Clin 1973;5:239-60.
4. Stanson AM, Kazmier FJ, Hollier LH, et al. Penetrating ath- erosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1986; 1:15-23.
5. Darling RC. Ruptured arteriosclerotic abdominal aortic an- eurysms: a pathologic and clinical study. Am J Surg 1970; 119: 397-401.
6. Szilagyi DE, Macksood AJ, Whitcomb JG. Expanding and ruptured abdominal aortic aneurysms. Arch Surg 1961;83: 83-96.
13. Sagel SS, Siegel MJ, Stanley RJ, Jost RG. Detection of ret- roperitoneal hemorrhage by computed tomography. AJR 1977; 129:403-7.
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15. Fitzgerald JF, Stilhnan RM, Powers JC. A suggested classi- fication and reappraisal of mortality statistics for ruptured atherosclerotic infrarenal aortic aneurysms. Surg Gynecol Ob- stet 1978;146:344-6.
16. Low A. A note on the crura of the diaphragm and the muscle ofTreitz. J Anat Physiol 1907;42:93-6.
17. Jones CS, ReiUy MK, Glover JL. Chronic contained rupture of abdominal aortic aneurysms. Arch Surg 1986;121:542-6.
18. Johnson G Jr, McDevitt NB, Proctor HJ, Mandel SR, Pea- cock JB. Emergent or elective operation for symptomatic ab- dominal aortic aneurysm. Arch Surg 1980;115:51-3.
