Multidisciplinary surgical management of a patient with an abdominal aortic aneurysm: how can we improve?

Abstract

INTRODUCTION: Abdominal aortic aneurysm (AAA) is a potentially fatal condition. Despite technical advances in surgical approaches, the Brazilian Unified Health System (SUS) presents challenges related to screening, early diagnosis, and resource availability. In addition to requiring a precise technical approach, complex aneurysms may require multidisciplinary care. CASE REPORT: A 72-year-old man with diabetes, hypertension, chronic kidney disease, and a history of smoking presented with abdominal pain. On admission, physical examination showed abdominal tenderness, a pulsatile mass, and palpable lower-limb pulses. Ultrasonography and computed tomography angiography showed a 7.1-cm infrarenal AAA and a 6.3-cm left internal iliac artery (IIA) aneurysm compressing the left ureter, which prompted the urology team to place a double-J ureteral stent. The vascular surgery team subsequently indicated endovascular treatment with embolization of the IIA aneurysm, but the procedure was unsuccessful because of its large diameter and unfavorable anatomy. The team chose open surgical repair with aneurysmectomy, an aortobi-iliac graft, and ligation of the left internal iliac artery. On postoperative day 2, the right lower-limb pulse became absent; computed tomography angiography showed thrombosis of the right external iliac artery. Surgery with passage of a Fogarty catheter was indicated to restore limb perfusion. The general surgery team was also called and identified diffuse bowel ischemia during surgery; total colectomy, segmental enterectomy, splenectomy, and ileostomy were performed. On postoperative day 9, the patient developed worsening general condition and hypotension. Imaging showed an incisional hernia, liver abscess, abdominal collections, and a rectal-stump fistula. The patient underwent another operation, which identified fecal matter in the abdominal cavity; mesorectal transection, ileostomy rematuration, and drainage of the cavity were performed. The patient developed refractory septic shock and died on hospital day 37. DISCUSSION: This was a highly complex case compounded by vascular complications and mesenteric ischemia. The outcome highlights the importance of multidisciplinary coordination and resource availability when managing complex cases. Ensuring these elements throughout high-complexity perioperative care is challenging and particularly critical within SUS, where delays can directly affect outcomes.