Rupture of abdominal aortic aneurysm between early and late phases of enhanced computed tomography

Ruptured abdominal aortic aneurysm (RAAA) is fatal in >80% of cases, and mortality is as high as 42% of those who survive RAAA and undergo surgery (42%). Sensitivity and specificity of computed tomography (CT) for the diagnosis of RAAA are reportedly not 100% but range from 50% to 94% and 77% to 100%, respectively. However, CT is still essential to verify anatomical details. A 90-year-old woman visited a community hospital with a complaint of right lower-quadrant pain. Plain CT revealed a double infrarenal AAA with respective diameters of 53 mm 60 mm and 55 mm 62 mm but no findings of rupture. The patient was transferred to our hospital with a blood pressure of 100/60 mmHg on arrival. Because the proximal neck of the AAA was short, enhanced CT was indicated to decide whether to perform endografting or replacement. Soon after the contrast was injected, CT showed minor leakage to the right side of the lower aneurysm (A, left panels), and the late-phase image obtained 105 seconds later revealed a massive hematoma in the right retroperitoneal cavity that had caused migration of the right kidney (A, right panels). The patient was successfully resuscitated from cardiopulmonary arrest, after which emergency surgery was indicated. Because no stent graft was available for emergency, replacement of the AAA was selected. After quick placement of an Equalizer aortic occlusion balloon (Boston Scientific, Marlborough, Mass) from the right femoral artery, the suprarenal aorta was exposed and clamped through a median laparotomy after systemic heparinization. Replacement of the AAA with a 16-mm 8-mm bifurcated Intergard graft (Maquet, Hudson, NY) was performed in the usual manner. The laparotomy wound was managed with a vacuum-assisted closure system to avoid abdominal compartment syndrome and was closed 4 days after the operation. The patient could be weaned from ventilator support 10 days later and has survived without any signs of brain ischemia. She gave written consent for publication of details of her case, including the radiologic images.