Review Question - QID 104028

This patient is at risk for ischemic bowel after an abdominal aortic aneurysm (AAA) repair and is the most likely etiology of the CT findings for this patient.

Patients undergoing AAA repair are at risk of ischemic bowel post-operatively. This is most likely seen due to decreased collateral circulation through the mesenteric system. Depending on the location of the aneurysm, the inferior mesenteric artery is often tied off during this operation and ischemia can ensue if insufficient collateral circulation is absent. In the event of significant vascular disease, emboli can also be sent downstream, occluding the distal-most mesenteric vessels. Pain out of proportion to physical exam is the classic finding of mesenteric ischemia.

Upchurch and Schaub discuss the diagnosis and management of AAAs. They advocate for the stable patient to be medically optimized before undergoing repair. Current randomized trials have shown no difference in morbidity and mortality between open and endovascular repairs.

Toya et al. review their own experience with embolic complications after endovascular AAA repair. They report that the presence of a shaggy aorta (severe arterial degeneration) and a history of smoking are independent predictors of embolic complications after an endovascular repair.

Image A is a CT scan displaying thumb printing during bowel ischemia. Thumb printing is caused by caused by thickened, edematous mucosal folds.

Incorrect Answers:
Answers 1,4: Adhesions are a likely cause of small bowel obstruction. On CT scan it is likely that a region of dilated bowel would be present proximal to the obstruction.
Answer 3: Bowel perforation would likely present as free air on an abdominal CT scan.
Answer 5: An abscess would appear as an enhancing fluid collection on abdominal CT scan.