A 46-year-old man was admitted with a 10-day history of left loin and back pain radiating to both groins. He also had symptoms of nausea and vomiting and a persistent low-grade fever. He had no urinary or bowel symptoms. Medical history was of type-2 diabetes only. On examination, he had abdominal tenderness in the left lower quadrant and was extremely tender over L3–L5 of the lumbar spine. His chest and abdominal X-rays were unremarkable, and urinalysis and intravenous urography were negative. His back pain was investigated with an MRI scan of the lumbar spine which was also normal. He was started on broad-spectrum antibiotics and fluid resuscitation. His inflammatory markers remained consistently elevated, with CRP ~170 mg/l, and WBC ~15 × 109.
Whilst awaiting CT imaging, the patient had a cardiovascular arrest, becoming severely hypotensive and tachycardic, pale and clammy, with a diminishing conscious level. He was taken to theatre for emergency repair of a presumed ruptured aortic aneurysm.
During laparotomy, he was found to have retroperitonal bleeding from an infra-renal, left-sided saccular abdominal aneurysm. We noted that there were extensive amounts of pus in the peri-aortic and pelvic regions. Swabs were sent for microbiology, cultures and sensitivities (these later grew Salmonella spp., sensitive to gentamicin and ciprofloxacin). There was also a large haematoma around the left kidney, which itself had become compromised. A left nephrectomy and evacuation of haematoma were performed and the left renal artery and vein were ligated. An axillobifemoral bypass graft was then performed to restore blood supply to the lower limbs after the ligation of the aorta (distal to the right renal artery) and common iliac arteries.
During this laparotomy, certain anatomical anomalies were observed: the bifurcation of the aorta was posterior the inferior vena cava (IVC), with the right common iliac artery running behind the IVC. The lumbar arteries arising from the ruptured section of the aorta were highly prominent and, on closer inspection, there were absent internal iliac arteries bilaterally. The enlarged lumbar arteries were probably compensating for the congenital absence of the internal iliac arteries, (see ).
Schematic diagram of the patient's arteries.
Postoperatively on ITU, the patient developed ischaemia and areas of necrosis around his buttocks, and his feet were cold and pulseless. He was taken back to theatre where he was found to have bleeding from the left common iliac artery, with a surrounding haematoma. The perforated vessel was repaired, and an aorto-ileal bypass graft was placed. Intra-operatively, good distal flow was confirmed with a hand-held Doppler.
Following these multiple vascular reconstructions, the areas of necrosis around the buttocks did not improve; the patient had multisystem organ failure and severe acidosis, and required high levels of inotropic and respiratory support. It was then decided that the degree of tissue necrosis was not salvageable and was so extensive that it was incompatible with life. The patient died on ITU following withdrawal of active treatment.