Patient Survives Ruptured AAA Against All Odds
Mr. T, a 78-year old retired attorney was supposed to be enjoying his 5 grandsons on a beautiful day in mid-December, but something did not feel right. He was experiencing severe abdominal pain and shortness of breath. At first, he thought it was just a case of bad indigestion. However, around 4pm, the pain progressed to a radiating pain and he had his daughter (an ICU nurse herself) take him to the Emergency Room at a major medical center to see what the issue might be.
He was immediately taken for a CT scan. The radiologist who first saw the scan immediately recognized a big problem - a large 8.6cm retroperitoneal abdominal aortic aneurysm (AAA). The Vascular Surgeon (“Dr. M”) who would be tasked with the ‘open repair’ knew it would be a complex case and called in CVSA Clinical Surgical Partner, Dr. Corinne Singh, to first-assist in the case. Just as he began discussing the procedure with Mr. T and his daughter, disaster struck. The large aneurysm ruptured and Mr. T slumped over and the EKG monitor showed Ventricular Fibrillation (aka “V-Fib”) and then quickly progressed to asystole. The code team was immediately in the room to begin resuscitative efforts as Dr. M called up to the O.R. alerting them of an urgent case coming up - a ruptured retroperitoneal AAA with the patient in full cardiac arrest. As Dr. M was rushing up to scrub-in, CVSA’s Singh arrived and immediately began scrubbing-in. Meanwhile, the code team wheeled Mr. T up to the Operating Room with ongoing chest compressions (ICU nurse riding the gurney pumping the chest).
The anesthesia and operating room staff started a bucket brigade of blood -there was enough staff to start a symposium. As Dr. Corinne entered the room, she was gloved-and-gowned and poured betadine on the chest. Just as Dr. M was getting gloved-and-gowned, Mr. T arrested again - Dr. Corinne immediately began chest compressions while Dr. M prepared for the massive incision. He cut him open from sterum to pubis and got the clamp on. It took 15 minutes of CPR (external and internal cardiac massage) to get a pulse back. The team was very pessimistic as during the case, ridiculously bad lab data came back like a pH of 6.9, lactate above 10, with no urine output.
Blood continued to pour out onto both Dr. M’s and Dr. Corinne’s scrubs and flooded the floor and their knee-high bootie shoe covers. Dr. M pushed his hand into the retroperitoneum, gently sweeping aside the torn tissues and blood clot to feel the hill of the aneurysm. Dr. Corinne walked over the slope of the aneurysm and tweedled her fingers around the aorta above the aneurysm. The cross-clamp rode Dr. M’s fingers into position around the aorta. The patient, so very dead minutes before in the ED, came back as Dr. Corinne began to feel a pulse above the clamp. The patient lived through the operation and the night where grim data -pH of 6.8, lactates in the double digits, four figure LFT’s, kidney failure all predicted a bad outcome.
Dr. M and Dr. Corinne both met with Mr. T’s daughter after the surgery and prepared her for a very poor outcome given the blood loss, amount of time where he was in asystole, and the myriad of other issues that occur when so much blood loss happens in a AAA rupture. Dr. M and Dr. Corinne identified the possible range of outcomes from full recovery (most unlikely) to Mr. T being left in a vegetative state from lack of perfusion to the brain causing neuro-hypoxia to death in the post-op SICU period.
Mr. T, with family by his side, began to show signs of improvement over the next 5 days in the ICU and eventually was moved to step-down. He ended up spending three weeks in the hospital during his long recovery which included dialysis, a tracheostomy, and a reboot of the brain -the brain takes a while to recover from the anoxia, but he was extraordinarily resilient, and he started to follow commands shortly after neuro rehab commenced. The morning before he was transferred to outpatient rehab in mid-January, Mr. T, his wife, and his daughter all spent time thanking his entire team, most notably his core surgical team including Dr. M and his very talented CVSA First-Assist, Dr. Corinne.
“Mr. T’s case is why I love high-stakes surgery. To see someone go from being clinically dead to alive and returning to his life of enjoying his family means everything. It’s easy to get caught up in the surgical aspect, but I always look to the ‘human side’ - that is what we fight for in the Operating Room. We fight for people and families - a residual effect that goes far beyond stats and outcomes. To be a trusted part of this continuum of care is a blessing.”
