CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 3, May/June 2014
e4
AFRICA
Case Report
Emergency endovascular aortic repair of a ruptured
mycotic aorto-iliac aneurysm presenting with lumbar
radiculopathy
Ting-Ying Lee, Chien-Sung Tsai, Yi-Ting Tsai, Chih-Yuan Lin, Yi-Chang Lin, Po-Shun Hsu
Abstract
Ruptured abdominal aortic aneurysm is life-threatening
without immediate management. The initial clinical pres-
entation is non-specific and impending rupture is easily
missed, especially without a CT scan. We present a case of a
56-year-old man with low-back pain and left lower-extremity
numbness, which was diagnosed as a herniated interverte-
bral disc (HIVD) with left acute sciatica syndrome. He also
complained of persistent fever and abdominal discomfort.
Routine blood work-up revealed leukocytosis and decreasing
haemoglobin levels. CT angiography (CTA) showed impend-
ing rupture of the left aorto-iliac aneurysm. We therefore
performed endovascular aneurysm repair (EVAR). Blood
culture revealed
Salmonella enterica
, for which he received
antibiotics. No acute sciatica syndrome was present immedi-
ately after the EVAR. No EVAR-related complications were
noted in the one-year CTA follow up.
Keywords:
endovascular aortic repair, mycotic aortic aneurysm,
lumbar radiculopathy
Submitted 9/3/14, accepted 25/4/14
Cardiovasc J Afr
2014;
25
: e4–e7
DOI: 10.5830/CVJA-2014-022
Mycotic aortic aneurysms (MAAs) are rare (1–1.8%) in aortic
abdominal aneurysms.
1
This is a secondary infection with an
abnormal aortic dilation and a pre-existing aneurysm, and may
result in an intractable infection or fatal complication. It may
be caused by direct bacterial inoculation, bacteraemic seeding,
contiguous infection, or septic emboli.
2
The clinical presentation of MAA is non-specific and includes
fever, chills and abdominal or back pain, and may therefore
lead to delayed diagnosis, resulting in aneurysm rupture and
associated fatal complications or mortality. Ruptured MAAs that
involve paravertebral soft tissue or the psoas muscle may cause
symptoms of lumbosacral radiculopathy, including neurological
deficits such as low-back pain, unilateral sciatica, limping, flank
pain or paraplegia.
3
Here, we present a rare case of a 56-year-oldmanwith amycotic
aortic aneurysm that presented as lumbosacral radiculopathy
with acute left sciatica syndrome, which was treated with
endovascular aneurysm repair (EVAR) and antibiotics.
Case report
The patient was a 56-year-old Taiwanese man who presented to
the emergency department with low-back pain radiating to the
posterior and lateral aspects of the left lower extremity, which he
had experienced over the last week. His vital signs were stable
and he had a mild fever (38.5°C). He complained of abdominal
fullness but had no obvious tenderness. The straight leg-raising
test was positive at 30°C for the left lower extremity.
Laboratory tests revealed leukocytosis (white cell count:
15 560 cells/
µ
l) and elevated C-reactive protein (CRP: 17.27
mg/dl). The initial impression was infectious spondylitis, and
spinal magnetic resonance imaging (MRI) was performed to
confirm the diagnosis. However, abdominal fullness persisted,
and decreased haemoglobin levels were noted (Hgb: from 12.6
to 9.7 g/dl) within 12 hours of admission.
CT angiography (CTA) revealed a saccular-type aneurysm
with an intramural thrombus measuring about 5.5
×
4.3
×
5.7 cm
(width, anterior–posterior depth and length) located at the distal
abdominal aorta, which resulted in acute haematoma formation
in the left lateral aspect of the aneurysm with the left psoas and
left iliac muscle extension. The size measured about 7.8
×
4.4
×
8
cm (width, depth and length). The proximal end of the aneurysm
was located 6.5 cm inferior to the left renal artery. In addition,
total occlusion of the left common iliac artery as well as the
proximal portion of the left external iliac artery was noted. The
contrast resulted in the development of an image over the distal
external iliac and left superficial femoral artery (Fig. 1).
We performed acute resuscitation and emergency EVAR.
Due to total occlusion of the left common iliac artery, the
guide-wire would not pass through the vessel. We implanted an
aortic–uni-iliac stent, 24 to 12 mm in diameter and an iliac stent
Division of Cardiovascular Surgery, Department of
Surgery, Tri-Service General Hospital, National Defense
Medical Centre, Taipei, Taiwan
Ting-Ying Lee, MD
Chien-Sung Tsai, MD
Yi-Ting Tsai, MD
Chih-Yuan Lin, MD
Yi-Chang Lin, MD
Po-Shun Hsu, MD,
