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.