Successful treatment journey for a patient with ruptured visceral aortic aneurysm with complications and a rare abdominal aortic aneurysm
The Ho Chi Minh City University of Medicine and Pharmacy Hospital (BV ĐHYD TPHCM) has just successfully treated a young patient with a visceral aortic aneurysm with rare rupture complications, forming a large blood clot that compresses causing biliary obstruction, gastrointestinal hemorrhage, and widespread arterial aneurysms. Given the complex condition, doctors consider this a difficult case with high mortality risk, so applying treatment methods must follow a correct and timely sequence to save the patient’s life.
Complex disease, high risk of death
This is the case of Mr. L.V.V., 37 years old living in Ho Chi Minh City. He was diagnosed with hypertension for more than 10 years, but because his health condition is stable, only feeling fatigued during strenuous activities, he has been complacent about regular health check-ups as well as treatmentHypertension. Recently, while working, Mr. V. suddenly felt dizzy, then vomited bright red blood, with severe epigastric pain. Mr. V. was taken by his family to the Ho Chi Minh City University of Medicine and Pharmacy Hospital emergency department.
After performing CT and upper gastrointestinal endoscopy, the doctors reported that Mr. V. had upper gastrointestinal bleeding suspected to be due to bleeding from the biliary tract from a hematoma and pseudoaneurysm accompanied by biliary obstruction caused by compression. The hematoma is large, with a diameter over 8 cm (located in the head and body of the pancreas) due to a pseudoaneurysm (28 mm diameter) that is active at the bifurcation of the celiac trunk, causing compression, biliary obstruction, and risk of rupture and extensive spread (due to ongoing bleeding). Laboratory tests clearly show the patient has cholestatic jaundice, with elevated bilirubin, liver enzymes increased to nearly 1000 UI/ml, and anemia.
According to Dr. Nguyễn Quang Thái Dương – Deputy Head of the Diagnostic Imaging Department, Head of the Vascular Intervention Unit at Ho Chi Minh City Hospital of Tropical Diseases, the patient has an abdominal aortic aneurysm and a lower thoracic aortic aneurysm with a background of hypertension. With this condition, the patient has a high risk of death if the false aneurysm continues to enlarge, and also has a risk of promoting severe progressive complications such as biliary obstruction and gastrointestinal bleeding.
CT image showing pseudoaneurysm mass and hematoma of the patient before intervention
Be cautious in planning treatment for the patient
Given the complex disease condition, high risk of complications and death when performing interventions on the patient, doctors conducted an interdisciplinary consultation between the Department of Hepatobiliary Surgery, the Department of Thoracic Vascular Surgery, the Department of Radiology, and the Vascular Intervention Unit to find an appropriate and safe treatment method for the patient. After the consultation, the doctors decided not to perform surgical or procedural interventions at the time of the consultation, avoiding “bức dây động rừng” and instead monitor the progression of bile duct obstruction and gastrointestinal bleeding because the intervention also carries a high risk of complications, including death (as the patient's clinical and hemodynamic condition was temporarily stable after admission).
Based on monitoring the patient’s clinical symptoms, tests, and ultrasound monitoring of the size of the subcapsular hematoma, the doctors assess that the clinical course is unfavorable, requiring a second consultation and deciding on endovascular intervention. The Vascular Intervention Unit performs the procedure with the goal of embolizing the pseudoaneurysm sac (preventing blood flow into the pseudoaneurysm sac), accepting the risk of possible occlusion of the hepatic artery and the splenic artery. Additionally, surgery is a backup option if the endovascular intervention fails or if there is a procedural complication that threatens the patient’s life.
“After considering the treatment options for the patient and the results of the background-removed vascular imaging, we decided to perform the first intervention by placing a covered alloy frame (stent graft) to seal the pseudoaneurysm sac and redirect flow into the hepatic artery. This is the safest method currently available for the patient, but it requires high technical skill due to the risk of complications (such as uncontrolled bleeding when there is a bleeding complication during the procedure, risk of splenic artery, hepatic artery occlusion, and not fully covering the pseudoaneurysm neck….) while also considering the next management approach depending on the disease progression immediately after the intervention”Dr. Nguyễn Quang Thái Dương shares.
Timely, effective intervention according to the patient's disease progression
The first intervention encountered many difficulties (due to abdominal aortic aneurysm, thoracoabdominal aortic root aneurysm, aneurysm located at the bifurcation, large aneurysm neck…) , the doctor performed stent graft placement with an 80% technical success rate (did not continue to achieve 100% due to high risk of complications such as rupture of the aneurysm from the technical manipulation) and still observed a small flow outside the stent into the aneurysm due to an overly wide aneurysm neck.
After the intervention, the patient was monitored for the pseudoaneurysm; if the stent graft achieves effective flow conversion and organization of the clot within the stent graft, the pseudoaneurysm will spontaneously reduce. One day after the first procedure, the patient no longer had biliary obstruction, and the biochemical indices (liver enzymes, total bilirubin) were completely normal. Ultrasound examination results showed that the pseudoaneurysm had shrunk to a diameter of only 20mm. The patient's health condition was stable, and he/she was discharged with antihypertensive medication, dual antiplatelet therapy, and a follow‑up appointment in two weeks.
At the follow-up visit after 2 weeks, the patient's health condition was stable. The CT results showed that the aneurysm had narrowed to a diameter of 16 mm, the hematoma reduced to 40 mm, the stent graft was placed normally regarding flow and hemodynamics while still recording high‑velocity flow along the outer surface of the stent into the aneurysm sac. With the hope that the aneurysm and hematoma will decrease over time, the patient will continue outpatient treatment with antihypertensive medication and single antiplatelet therapy with clopidrogel (instead of dual antiplatelet therapy with clopidrogel and aspirin).
CT image shows the patient's blood clot slightly reduced after the intervention
10 days later, the patient went to the emergency department due to sudden abdominal pain and jaundice. Ultrasound and CT results showed that the pseudoaneurysm sac was enlarging and the stent graft was completely occluded. The patient was counseled and proceeded with a second intervention to completely occlude the pseudoaneurysm sac.
During the second intervention, the doctors placed 6 coils with a total length of more than 3.6 meters (each coil 60 cm long, 1 mm diameter) to fill the pseudoaneurysm. The coil placement technique was facilitated by the alloy frame placed in the first session serving as a pelvic frame. After the procedure, the pseudoaneurysm was filled and no longer active. The splenic artery was preserved; the common hepatic artery was completely occluded (as expected) but the liver was not affected because the portal vein still supplied it. One day later, the patient was discharged in stable condition, with no remaining risk of complications as the pseudoaneurysm sac had been completely resolved.
According to Dr. Nguyen Quang Thai Duong, rupture of a visceral artery aneurysm is a very rare disease, and rupture of a true aneurysm forming a blood clot and an active pseudoaneurysm with complications of biliary obstruction and gastrointestinal bleeding is even rarer. This disease is extremely dangerous because even a small aneurysmal sac carries a very high risk of rupture. When rupture occurs, the mortality rate is almost over 70‑80%, especially for large sacs located at bifurcations and accompanied by an abdominal aortic aneurysm. Treatment intervention for patients requires high technical skill according to an appropriate protocol. Endovascular intervention is the primary choice for aneurysmal sacs or pseudoaneurysms situated in locations difficult to treat surgically.
CT image after coil placement procedure filling the pseudoaneurysm
Dr. Nguyen Quang Thai Duong advises that individuals with a history of smoking, hypertension, previous vascular diseases, or family members with arterial disease should proactively undergo regular check-ups to receive proper treatment for underlying conditions, avoiding high risk of complications when an incident occurs. As soon as abdominal symptoms appear, patients should go to a medical facility to be examined by a doctor and receive timely treatment.