The 87-year-old Tan Laohan (pseudonym) from Songzi City, Hubei Province suddenly felt severe abdominal pain after getting up in the morning and couldn’t bear it. His children took the elderly to the emergency department of a local hospital for treatment. A CT scan of the abdomen showed that there was a huge mass in the abdomen of the old man, about 9 cm in diameter. The initial diagnosis was an abdominal aortic aneurysm.
Once the abdominal aortic aneurysm ruptures, the spewing blood will flow out within 3 minutes, and the patient’s mortality rate is extremely high. The local hospital immediately transferred the patient to the Department of Interventional Vascular Surgery, Jingzhou First People’s Hospital. After enhanced CT examination in the emergency department, Tan Laohan was diagnosed with “threatening ruptured abdominal aortic aneurysm.” The diameter of the abdominal aorta of a normal person is about 1.5 cm, while the old man Tan is as large as 9 cm, and part of the tumor wall has been torn, and blood has extravasated! Severe abdominal pain indicates that his abdominal aortic aneurysm is on the verge of rupture, and this “bomb in the human body” may “explode” at any time.
Surgical treatment of threatened ruptured abdominal aortic aneurysm includes minimally invasive intervention and artificial blood vessel replacement. Minimally invasive intervention requires a stent to be inserted into the blood vessel, but the hospital does not have a storage stent and needs to be transferred from the pharmaceutical company; and Tan Laohan is in critical condition and cannot wait, so he can only choose artificial blood vessel replacement. The open surgery is too traumatic. The elderly is 87 years old, and there are many basic diseases such as severe scoliosis, bronchiectasis in both lungs, and one-third damage to the right lung. If there is any carelessness during the operation, the elderly may die at any time. On the operating table.
“Life is more important than everything. Even if there is no matter how great the difficulties and risks are, as long as there is a glimmer of hope, we can’t give up!” The interventional vascular surgery team decided to implement open surgery for the elderly. To prevent massive bleeding during the operation, the brachial artery of the left arm was approached before the operation, and a blocking balloon was placed above the abdominal aortic aneurysm. When the abdominal aortic aneurysm is completely dissected, if the hemostatic forceps still cannot stop the bleeding, immediately open the balloon to stop the bleeding, which is equivalent to a “double insurance”. The surgeon can continue the operation without worrying about fatal bleeding.
Open the patient’s abdominal cavity, only part of the intestinal tract in the abdominal cavity is densely adhered. Hematoma infiltration has appeared around the huge tumor in the posterior peritoneal cavity, and the expansion of the tumor involves the iliac arteries on both sides, and there is a fatal risk of rupture and bleeding at any time. After discussion on the stage of the surgical team, considering that the left common iliac and internal and external iliac arteries have been expanded like tumors, in order to ensure the safety of the operation, it was decided to ligate the left common iliac, internal and external arteries, and to artificial blood vessels for bilateral common iliac, External iliac artery anastomosis. After 5 hours of surgery, the abdominal aortic artificial blood vessel replacement was successfully completed. Tan Laohan transferred from the operating room to the neuro-intensive care unit.
Three days after the operation, the old man recovered well and was transferred to the interventional vascular surgery ward. After another 10 days of postoperative treatment and care, the old man was finally discharged safely.
What is abdominal aortic aneurysm
With the diaphragm as the boundary, the aorta is divided into the thoracic aorta and the abdominal aorta (see Figure 1). The abdominal aorta is the aorta of the human abdomen. Abdominal aortic aneurysm is a disease caused by the expansion and expansion of the abdominal aorta of the human body to a certain extent due to some reasons.
Abdominal aortic aneurysm is relatively new to everyone, but this disease is actually not uncommon. Einstein and Li Siguang suffered from abdominal aortic aneurysm. Abdominal aortic aneurysm is not a tumor. It is a rupture of the intima of the abdominal aorta, forming a dissection. Blood accumulates between the inner and outer lining of the blood vessel, causing the blood vessel to expand like a balloon (see Figure 2). If the abdominal aorta suddenly enlarges and expands to a certain extent, it is likely to rupture and cause fatal bleeding, as if the balloon was blown.
The mortality of patients with ruptured abdominal aortic aneurysm can reach more than 90%. Therefore, the medical profession also calls the abdominal aortic aneurysm a “time bomb” in the human body. Abdominal aortic aneurysms are more common in the elderly, especially those with atherosclerosis. Among 65-year-olds, the incidence is about 8%.
How big an aneurysm is dangerous
How large is the abdominal aorta expansion can be called an aneurysm, and how specific is the tumor at risk? Generally speaking, the diameter of the abdominal aortic aneurysm is twice or more than the surrounding normal blood vessel. The diameter of the normal abdominal aorta is about 1.5 cm to 1.8 cm. More than double this value is called an aneurysm. If it continues to expand, close to 4 to 5 cm or more, then the danger is very great. The current international standard is that if the aneurysm is close to 5 cm, or the aneurysm is less than 5 cm, but the expansion speed is relatively fast, an increase of 7 mm in half a year, then it is more dangerous. Therefore, if the aneurysm grows rapidly or is close to 5 cm in size, you should seek medical advice in time. In addition, female patients need active treatment even if the aneurysm diameter is less than 5 cm.
What are the symptoms of abdominal aortic aneurysm
Abdominal aortic aneurysm is usually asymptomatic in its early stage, or when it has not reached a certain level. Abdominal aortic aneurysms with a diameter of less than 4 cm have a relatively low risk of rupture. The patient has no obvious symptoms and too much pain, but occasionally touches a beating mass in the abdomen. Therefore, it is usually not easy to find early. As the aneurysm enlarges, obvious symptoms will appear.
The first symptom is pain. When the pain gets worse, it often indicates that the aneurysm is about to rupture, or even ruptured, and then it will be too late. Sometimes the patient will feel faint pain, this is because the mass is large and uncomfortable there. With a larger diameter abdominal aortic aneurysm, the outer shell becomes very thin, and it will feel painful when pressed.
Another symptom is arterial embolism. Due to the local enlargement of blood vessels, a vortex will be generated when the blood flows; this vortex will cause thrombus formation in the inner layer of the artery wall, which is the so-called mural thrombus in medicine. Once these thrombi fall off, they will flow to the lower extremities with the blood flow, causing embolism of the lower extremity arteries. The patient will present with sudden pain in the lower limbs and may even be unable to walk. Some patients find abdominal aortic aneurysm because of lower limb ischemia. Therefore, most aneurysms are found occasionally by patients themselves, and some patients’ aneurysms are found during normal physical examinations. For example, a physical examination for liver, gallbladder, kidney and spleen B ultrasound, abdominal or pelvic CT examination, accidentally found a large bulge in the aorta.
How to treat abdominal aortic aneurysm
Generally speaking, asymptomatic abdominal aortic aneurysms below 3 to 4 cm can be treated conservatively without surgery. Conservative treatment is to control arteriosclerosis and change bad habits, such as quitting smoking, adjusting diet, and controlling high blood pressure. At the same time, doppler ultrasound or CT examination should be done every six months to one year to understand the progression speed and size changes of the aneurysm. When the aneurysm has reached more than 5 cm, it is necessary to consider surgical intervention. Because at this time, the rate of aneurysm rupture is relatively high and the risk is high.
There are currently two main surgical treatments for aneurysms. One is artificial blood vessel replacement. A large incision is made in the abdomen to find the aortic aneurysm and then remove it. The missing aorta is replaced with an artificial blood vessel. Artificial blood vessel replacement is currently the most important treatment method, and the treatment cost is relatively low.
Another surgical treatment is the rapid development of stent technology in the past ten years. A large stent with a membrane is placed in the aortic lumen to isolate the blood vessel lumen. The so-called isolation is to put the stent inside the blood vessel so that the blood flows in the stent without creating pressure on the aneurysm wall to prevent the aneurysm from continuing to expand, thus avoiding the risk of aneurysm rupture. This technique is a relatively new technique, and the trauma is relatively small. It can be solved by only cutting a small incision of four to five centimeters in length at the roots of the thighs on both sides. This operation needs to be done under a large imaging machine. This is called endovascular isolation, also called endovascular stent implantation.