Article, Cardiology

Acute respiratory distress as an initial presentation of acute aortic occlusion

Case Report

Acute respiratory distress as an initial presentation of acute Aortic occlusion

Abstract

Acute aortic occlusion is a devastating and often fatal event. It occurs most often in elderly patients with severe comorbidities and requires prompt recognition and immediate surgical intervention. However, the rarity of aortic occlusion and the fact that it often has atypical clinical manifestations may delay diagnosis and impact prognosis. In this study, we present for first time a case of an 83-year-old female patient who had acute aortic occlusion and was admitted with acute respiratory distress. However, the detailed clinical examination and the correct interpretation of the laboratory findings expedited diag- nosis and allowed prompt revascularization surgery, by means of extra anatomic axillobifemoral bypass under local anesthesia.

An 83-year-old female patient, with a known history of dementia, was admitted to the acute and emergency unit with acute respiratory distress. According to her escort, the symptoms appeared suddenly 1 hour before admission while the patient was sleeping. Patient’s other medical history included hypertension, atrial fibrillation, and a stroke 5 years ago. She was on treatment with clopidogrel, digoxin, and nebivolol.

On admission, she was on respiratory distress (pulse oximetry: 170 beats/min, and 80% O2 saturation on Room temperature), tachypnoic (28 breaths/min), sweaty, and cold with a temperature of 35?C. Her blood pressure was 100/60 mm Hg, whereas her chest auscultation demon- strated bilateral rales. The pulse was weak in the upper extremities and carotids and not palpable in lower extremities, whereas all efforts to obtain arterial blood gasses were unsuccessful. The initial differential diagnosis included sepsis, pulmonary embolism, pulmonary edema, and acute myocardial infraction.

Baseline biochemical profile and prothrombin time were normal, whereas full blood count test showed a normal hematocrit (38.5%), elevated white blood cell count

(22.65 K/uL), and a platelet count of 120 K/uL. Chest x-ray revealed moderate enlargement of the cardiac silhouette, with signs of pulmonary congestion, whereas the electrocardiogram showed atrial fibrillation and no signs of ischemia (Fig. 1). She was treated with 100% oxygen at 12 L and 250 mcg digoxin intravenous. A temporary improvement of her clinical status was noticed. Bedside echocardiography was performed to exclude massive pulmonary embolism. This revealed a nondilated but hypertrophic left ventricle with Severe systolic dysfunction due to global hypokinesia (ejection fraction: 15%). Bi-atrial dilatation was noted, whereas the aortic root had normal dimensions. The valves were normal and the right ventricle was not dilated and contracted well. The pulmonary artery systolic pressure was estimated 30 mm Hg. The right ventricular indices ruled out massive pulmonary embolism, whereas the severe left ventricular systolic dysfunction was attributed to her tachycardia, as the patient did not have a history or sings of chronic heart failure on clinical examination.

Because these findings did not confirm a specific diagnosis, the patient was reassessed and the clinical examination was repeated. This confirmed the absence of pulses in low extremities, and thus, a Doppler wave examination was performed and revealed absent wave forms in both femorals arteries. During the Doppler examination, the patient developed cyanosis in both legs. Hence, computed tomography of the thoracic and abdom- inal aorta was performed and revealed acute thrombosis of the infrarenal abdominal aorta (Fig. 2).

The patient was taken to the operating theater, and after unsuccessful attempts of retrograde embolectomy, emer- gent right axillobifemoral bypass was performed using 8- mm polytetrafluoroethene grafts to restore the blood flow to the lower extremities. Patient’s postoperative course was complicated by a profound fall of the hematocrit the second postoperative day, attributed to a large subcutane- ous hematoma of the right side, in the course of the graft canal probably caused by the intense anticoagulation treatment (Fig. 3). This was managed conservatively with regional tamponade, blood, and fresh frozen plasma transfusion. The rest of the patient’s postoperative course

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Fig. 1 Chest x-ray on admission showing atelektasia in the right upper lobe, moderate cardiac silhouette enlargement, and opacities that extend outward from the hilum suggesting pulmonary congestion.

was unremarkable, with complete restoration of the blood flow in both lower extremities and an ankle-brachial index of 0.7 upon discharge.

Acute aortic occlusion is a rare event that most often occurs in elderly patients with advanced cardiac disease and is associated with high morbidity and mortality [1,2]. Its typical clinical presentation includes the classic 6 “P’s”: pain, paresthesia, paralysis, pallor, pulselessness, and poikilothermia [3]. However, in contrary to what might be expected, a considerable number of patients maybe

Fig. 2 Computed tomographic image showing the presence of a thrombus (arrow) in the infrarenal abdominal aorta.

Fig. 3 Postoperative computed tomographic image demonstrat- ing a large subcutaneous hematoma of the right side (arrow), in the course of the graft canal.

admitted complaining for atypical symptoms such as abdominal pain or hypertension [4]. The rarity of aortic occlusion and the fact that it often has atypical manifes- tation may delay diagnosis and thus lead to limb loss and worse prognosis [5,6].

This case report presents an atypical manifestation of acute aortic occlusion. Our patient had dementia and a previous stroke that rendered impossible the precise assessment of her symptoms and the identification of new neurologic deficits, whereas her initial symptoms–respi- ratory distress caused by acute heart failure due to a catecholamine driven tachycardia and probably to an acute increase of peripheral resistances–initially mislead the physicians. Nevertheless, in this setting, the detailed clinical examination and the correct interpretation of the findings from the diagnostic tests expedited the correct diagnosis, minimized the Ischemic time, and contributed to the optimal outcome.

Emmanouil D. Psathas MD Second Department of Propedeutic Surgery University of Athens, Medical School

Laiko General Hospital, Athens, Greece

Christos V. Bourantas MD, PhD Department of Cardiology, Castle Hill Hospital Castle Road, Cottingham, Kingston upon Hull

East Yorkshire, UK E-mail address: [email protected]

Case Report

Dimitrios G. Parthenis MD, MSc Christos Verikokos MD, PhD

References

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Second Department of Propedeutic Surgery University of Athens, Medical School

Laiko General Hospital

Athens, Greece

Thekla Geragotou MD

First Department of Propaedeutic Medicine Laiko General Hospital, Athens University Medical School

Athens, Greece

Grigorios Kouraklis MD, PhD Second Department of Propedeutic Surgery University of Athens, Medical School

Laiko General Hospital

Athens, Greece

doi:10.1016/j.ajem.2010.02.013

  1. Drager SB, Riles TS, Imparato AM. Management of acute aortic occlusion. Am J Surg 1979;138:293-5.
  2. Abbott WM, Maloney RD, McCabe CC, Lee CE, Wirthlin LS. arterial embolism: a 44 year perspective. Am J Surg 1982;143(4):460-4.
  3. Surowiec SM, Isiklar H, Sreeram S, et al. Acute occlusion of the abdominal aorta. Am J Surg 1998;176:193-7.
  4. Babu SC, Shah PM, Nitahara J. Acute aortic occlusion-factors that influence outcome. J Vasc Surg 1995;21(4):567-72.
  5. Meagher AP, Lord RS, Graham AR, Hill DA. Acute aortic occlusion presenting with lower limb paralysis. J Cardiovasc Surg 1991;32:643-7.
  6. Blaisdell FW, Steele M, Allen RE. Management of acute lower extremity arterial ischemia due to embolism and thrombosis. Surgery 1978;84:822-34.

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