Case Presentation
This case report has been approved by the ethics committee of our
institute. The patient provided informed consent for the publication of
this report.
A 63-year-old man with complaints of fever for one week, sudden lower
back pain, and hypotension was admitted to our hospital. On admission,
he had a temperature of 40℃, an elevated white blood cell count
(249×102/μL) and a C-reactive protein level of 15.6
mg/dL. The patient had a history of hypertension, smoking, and had
undergone replacement of the descending aorta for a dissecting aortic
aneurysm six years ago. Computed tomography (CT) of the remaining
thoracoabdominal aortic lesion showed no aortic dilatation (Figure 1).
The CT scan also revealed an acute
rupture of the adventitia and a hematoma in the retroperitoneal space
(Figure 2). He was diagnosed with infectious rupture of a dissecting
TAAA. Emergency thoracoabdominal aortic replacement with omental flap
wrapping was performed.
Dissection of the aorta just superior to the renal artery resulted in an
abscess outflow and it was into the abdominal cavity. Following complete
excision of the aneurysm, the abdominal aorta and the renal artery were
reconstructed using a rifampicin-soaked Gelweave Coselli
Thoracoabdominal Graft (Terumo Corporation, Tokyo, Japan). The proximal
side of the dissected aorta was anastomosed to the prosthetic aortic
graft from the previously replaced descending aorta. Since the aortic
dissection extended to both the iliac arteries, the abdominal aorta was
also replaced using a Gelsoft Bifurcated Graft (Terumo Corporation,
Tokyo, Japan). After weaning the patient from cardiopulmonary bypass,
the omentum was passed into the retroperitoneal cavity through an
incision in the ligament of Treitz and wrapped around the prosthetic
aortic grafts.
C. freundii was detected in the intraoperative retroperitoneal
abscess, preoperative and postoperative blood cultures. The culture
produced cephalosporinase (AmpC) and showed innate resistance to various
penicillin antibiotics, such as ampicillin and early-generation
cephalosporins.
There was no preoperative nerve paralysis; however, the patient
developed paraplegia on postoperative day one.
Spinal drainage showed no
improvement in the patient’s symptoms. Long-term carbapenem antibiotics
were required to treat the AmpC-producing C. freundii; however,
the patient consequently developed pseudomembranous enteritis caused byClostridioides difficile . Vancomycin and Fidaxomicin were used to
treat C. difficile . The patient was discharged on postoperative
day 255. The blood culture at discharge was negative. A CT scan
performed at the time of discharge showed no anastomotic complications
or retroperitoneal fluid retention (Figure 3). However, the paraplegia
persisted.