Article, Cardiology

Significant changes in combined consistent biomarkers and CTAngiography revealed during an interval of 6 months before abdominal aortic aneurysm rupture

a b s t r a c t

The most commonly used predictor of rupture of Abdominal aortic aneurysm is the diameter, but this does not correlate well with the risk of rupture. Therefore, in order to make further improvements in Clinical decisions regarding AAA patients, the development of additional Predictive tools other than aneurysm size alone is needed. We herein report a case of a 72-year-old man with AAA that underwent rupture transformation during six months. We review the morphological features changes detected by computed tomography and also observe several alters circulating biomarkers at the same time. In the study presented essentially an association of those combined parameters with the risk of AAA impending rupture.

(C) 2017

Various predictors have been reported with abdominal aortic aneu- rysm (AAA) impending rupture, independently of aneurysm diameter, which is the most commonly used predictor, however not correlated well with the risk of rupture. A maximum diameter of 55 mm and an ex- pansion rate of 10 mm/year are generally used as thresholds to recom- mend elective endovascular or open AAA repair. It has been recognized that the intraluminal thrombus (ILT) is a biologically active material contributing in the progression and rupture of AAA. The order of the pathological events and their direct contribution to AAA, are not yet understood.

Many biomarkers related to AAA outcome are not disease specific. Research is required to establish the underlying relations between these biomarkers and their role in aneurysm pathophysiology. There- fore, in order to make further improvements in clinical decisions regard- ing AAA patients, we examined in this case, morphological parameters based on the CTA and combined consistent biomarkers as potential pre- dictor of AAA rupture.

A 72-year-old man was admitted to the cardiology unit because of Hypertrophic cardiomyopathy, hipertension and atrial fibrillation. During echocardiography examination asymptomatic incidental AAA was revealed. Intact aneurysm with 87 mm maximal diameter was

* Corresponding author at: Department of Vascular Surgery and Angiology, Al. Powstancow Wielkopolskich 72, 70-111 Szczecin, Poland.

E-mail address: [email protected] (I. Wiernicki).

confirmed by a Computed tomography angiography dated 2 April 2016 (Fig. 1A, B). Patient had undergone CTA examination with Contrast enhancement in the arterial pHase and the slice thickness was

0.6 mm. Measurements of morphological aneurysm sac parameters were performed by using medical imaging software (OsiriX MD 64-bit software version 2.6; certified for medical imaging; Pixmeo, Bernex, Switzerland). For AAA that attains a size of N 8 cm, the risk of rupture may exceed 25% at 6 months [1]. However, this patient refused a prop- osition of endovascular aneurysm repair. He was discharged from the hospital in good condition with recommendation for future treatment in vascular surgery unit.

After six month patient with strong pain in the right side of abdomen was brought to department of vascular surgery and angiology by emer- gency services. Basic blood tests (hsCRP and D-dimer included), electro- cardiography, and imaging studies were performed. CTA dated 30 September 2016 revealed 88,6 mm infrarenal AAA rupture with retro- peritoneal huge hematoma (Fig. 1C, D). Because of lack of matched aortic stentgraft in this time of treatment and decrease in value of blood pressure (57/34 mm Hg) patient had an emergency open surgery by implantation of aortobiiliac external prosthesis (Gelsoft 20/10). Dur- ing AAA repair on the anterior wall of sac, site of rupture was detected. After the aneurysm Open repair, patient was under treatment in an emergency intensive care unit of a university-affiliated hospital for 3 days. He has subsequently been followed up clinically without further complication. This study describes not only changes of morphological

http://dx.doi.org/10.1016/j.ajem.2017.02.047

0735-6757/(C) 2017

1039.e2 P. Szumilowicz et al. / American Journal of Emergency Medicine 35 (2017) 1039.e11039.e3

Fig. 1. Axial and sagittal enhanced CTA images (A and B) obtained 6 months before AAA rupture. Axial and sagittal CTA angiograms (C and D), from the exact scan level after 6 months, showing the rupture with bleeding from the patent lumen of a 88,6 mm AAA into the peripheral thrombus and large right Retroperitoneal hematoma with contrast extravasation from anterior wall of aneurysm (arrows). Contained aneurysm anterior wall discontinuity and associated organized hematoma was present at surgery.

features detected by CTA, but also simultaneously alters clinical com- bined consistent biomarkers of patient implicated in this time of impending AAA rupture. The data are presented in Table 1.

In this case, after six-month follow-up of AAA patient, CTA revealed bleeding into the ILT (Fig. 1C, D). Roy et al. reported that the rupture of an AAA is associated with bleeding into the ILT [2]. Notice that in our previous study, we reported that blood flow channel (BFC) index value correlated with bleeding into the thrombus and N 14.5 predicts the likelihood and timing of rupture. A BFC index was formulated as: maximal/minimal thickness ratio of ILT from the same CTA scan [3]. In present case BFC index value significantly increased during a 6 month period before AAA rupture (Table 1). plasma markers of inflammation

Table 1 Comparison of morphological parameters and clinical biomarkers between asymptomatic and rupture stage of the same case of AAA – results of six-month follow-up of patient.

AAA Asymptomatic stage Rupture stage

include CRP and Fibrin degradation products include D-dimer are ele- vated in large AAAs. Vele et al. observed a strong positive correlation be- tween AAA progression and increasing plasma D-dimer concentration over a 12-month period [4].

Some authors reported that preoperative Neutrophil to lymphocyte ratio N 5 is an independent predictive marker of 30-day mortality in ruptured AAAs and also predicts preoperative mortality following open elective repair of aneurysms [5,6]. In our patient peripheral blood NLR ratio was higher than 5 in AAA rupture stage (Table 1).

We suggest that changes of morphological parameters and increase of combined consistent biomarkers may have occurred just before the clinical symptoms of AAA rupture. Therefore, it is recommended that monitoring of BFC – index, CRP, D-dimer and NLR in AAA outpatients may support the clinical decisions regarding aneurysm b 55 mm Surgical repair and show great potential for clinical translation. Further studies in large patients group with small aneurysms are needed to confirm a better correlation presented of those combined parameters with the risk of AAA rupture.

nterest

Maximum diameter (mm) Rupture region diameter (mm)

87

75

88.6

81.4

Conflict of i

Maximum ILT thickness (mm)

35

32

Minimum ILT thickness (mm)

1.8

1.1

None.

BFC-index

19.4

29.1

AAA volume (cm3)

414.5

488.0

ILT volume (cm3)

104.8

141.9

References

BFC volume (cm3)

309.7

346.1

CRP (0-5 ng/mL) 6.6 118.0

D-dimer (0-500 ng/mL) 1451 10 623

NLR 0.6 7.75

ILT – intraluminal thrombus, BFC – blood flow channel, AAA – abdominal aortic aneurysm, CRP – C-reactive protein, NLR – neutrophil to limphocyte ratio.

  1. Lederle FA, Johnson GR, Wilson SE, Ballard DJ, Jordan Jr WD, Blebea J, et al. Rupture rate of large abdominal aortic aneurysm in patients refusing or unfit for elective re- pair. JAMA 2002;287:2968-72.
  2. Roy J, Labruto F, Beckman MO, Danielson J, Johansson G, Swedenborg J. Bleeding into the intraluminal thrombus in abdominal aortic aneurysms is associated with rupture. J Vasc Surg 2008;48:1108-13.

P. Szumilowicz et al. / American Journal of Emergency Medicine 35 (2017) 1039.e11039.e3 1039.e3

  1. Wiernicki I, Szumilowicz P, Kazimierczak A, Falkowski A, Rutkowski D, Gutowski P. The blood flow channel index as novel predictor of abdominal aortic aneurysm impending rupture based on the intraluminal thrombus angio-CT study. Eur J Radiol 2015;84:662-7.
  2. Vele E, Kurtcehajic A, Zerem E, Maskovic J, Alibegovic E, Hujdurovic A. Plasma D- dimer as a predictor of the progression of abdominal aortic aneurysm. J Thromb Haemost 2016;14:2298-303.
  3. Kordzadeh A, Malietzis G, Browne T, Prionidis I, Panayiotopoulos YP. Neutrophil to lymphocyte ratio (NLR) of five predicts 30-day morbidity in ruptured abdominal aor- tic aneurysms (rAAA): a retrospective cohort study. Int J Surg 2015;15:45-8.
  4. Appleton ND, Bailey DM, Morris-Stiff G, Lewis MH. Neutrophil to lymphocyte ratio predicts preoperative mortality following open elective repair of abdominal aortic an- eurysms. Vasc Endovascular Surg 2014;48:311-6.

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