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Washington University Experience | VASCULAR | Infarct - Spinal Cord | 12A0 Case 12 History
Case 12 History ---- The patient was a 79 year old man who was admitted for elective repair of a thoracic-abdominal aortic aneurysm which had enlarged to over 5 cm in diameter over the past year. The patient's past medical history included hypertension, a myocardial infarction in 1989 during a failed angioplasty procedure, left carotid endarterectomy in 1993, TURP (1989) and appendectomy (1996). The patient's medications included atenolol, lorazepam, aspirin, Pepcid and dynacirc. Clinical examination at the time of admission was remarkable for a non-tender pulsatile mass, 5-6 cm, palpable to the right of umbilicus, consistent with the patient's aneurysm. His routine blood workup was unremarkable. A cardiac echogram showed no wall motion abnormalities and a normal left ventricular ejection fraction. The aneurysm repair was performed on 10/29. Overall, bypass grafting was performed from the mid-thoracic portion of the aorta to the distal aorta (preserving a visceral patch, containing the origin of renal, superior mesenteric and celiac arteries). Also, bypass grafting was performed to right common iliac and left external iliac arteries. The immediate postoperative course was unremarkable and the patient was able to adequately move both lower extremities. However, the next 24 hrs. were complicated by acute renal failure, paraplegia and ischemia of the left great toe. All these complications persisted until the time of death. Creatinine levels raised to 6.5 with a BUN of 159, eventually requiring hemodialysis that was started approximately postoperative day #9. Another complicating event of the postoperative course was non-infectious adult respiratory distress syndrome requiring ventilatory support. By postoperative day #9 there was marked improvement in the ventilatory/oxygen requirement in this patient. Another complication was the development of atrial fibrillation that resisted electric cardioversion and resolved with medications. Although no infectious agent could be isolated at any point from this patient's cultures he was kept on broad antibiotic coverage for prophylaxis. Approximately postoperative day #9 the patient was noted to acutely deteriorate with worsening of his respiratory function, increased vaso-pressor requirement and increased white blood counts. This was attributed to possible complicating sepsis. Provided the patient's age the prognosis was grim and, the family, informed of this, decided to withdraw intensive supporting measures. The patient expired soon thereafter.
