Abbasi Danish, Vanhook Jeffrey E, Salartash Khashayar, Levite Howard
AtlantiCare Regional Medical Center, USA.
Lewis Katz School of Medicine at Temple University, Department of Medicine, USA.
Case Rep Vasc Med. 2018 Nov 21;2018:6273538. doi: 10.1155/2018/6273538. eCollection 2018.
We present a case of a 78-year-old female with history of diastolic heart failure and paroxysmal atrial fibrillation on apixaban presenting with worsening shortness of breath. She underwent transesophageal echocardiogram showing severe aortic stenosis with a valve area of 0.8 cm2. Coronary angiography did not reveal significant coronary artery disease. CT of chest, abdomen, and pelvis did not show any evidence of hematoma or dissection. Patient was scheduled for transfemoral TAVR. Patient's apixaban was discontinued prior to the procedure. She received heparin during the procedure. She successfully underwent left transfemoral aortic valve replacement. Shortly after the procedure, she complained of abdominal pain and became hypotensive. Blood pressure was 76/44 mm of Hg (MAP 58). Hemoglobin dropped to 8.1 g/dl (baseline 13). Stat CT abdomen and pelvis showed a large volume of hemorrhage in the peritoneal cavity. CTA of abdomen showed no evidence of aortic aneurysm or dissection but active extravasation below the inferior aspect of the spleen. Catheterization of the superior mesenteric artery (SMA) identified ileal branch of SMA as the source of bleeding. Embolization using gel foam slurry followed by a coil insertion was performed. Repeat angiogram demonstrated continued extravasation through arcade collaterals. A rapid exploration of the abdominal cavity revealed ruptured mesenteric hematoma. Evacuation of hematoma was performed. Portion of small ileum and bleeding mesenteric branch vessel was resected. Her condition stabilized with no postoperative bleeding and she was discharged on warfarin postoperatively. Use of antithrombotic therapy increases risk of bleeding in TAVR patients. Mesenteric hematoma rupture if not identified can be life-threatening. We believe that this is the first reported case of mesenteric hematoma rupture after a TAVR procedure.
我们报告一例78岁女性病例，该患者有舒张性心力衰竭病史，正在服用阿哌沙班治疗阵发性心房颤动，现出现气短加重症状。她接受了经食管超声心动图检查，结果显示严重主动脉瓣狭窄，瓣膜面积为0.8平方厘米。冠状动脉造影未发现明显的冠状动脉疾病。胸部、腹部和骨盆的CT检查未显示任何血肿或夹层的迹象。患者计划接受经股动脉经导管主动脉瓣置换术（TAVR）。术前停用了患者的阿哌沙班。术中给予肝素治疗。她成功接受了左股动脉主动脉瓣置换术。术后不久，她主诉腹痛并出现低血压。血压为76/44毫米汞柱（平均动脉压58）。血红蛋白降至8.1克/分升（基线为13）。急诊腹部和骨盆CT显示腹腔内大量出血。腹部CT血管造影未显示主动脉瘤或夹层的迹象，但在脾脏下缘下方有活动性造影剂外渗。肠系膜上动脉（SMA）插管显示SMA的回肠分支为出血来源。使用明胶海绵糊剂栓塞，随后置入线圈。重复血管造影显示通过弓状侧支仍有造影剂外渗。迅速探查腹腔发现肠系膜血肿破裂。清除血肿。切除部分小肠和出血的肠系膜分支血管。她的病情稳定，术后无出血，术后出院时服用华法林。抗血栓治疗会增加TAVR患者出血的风险。肠系膜血肿破裂如果未被识别可能会危及生命。我们认为这是首例报道的TAVR术后肠系膜血肿破裂病例。
