Multiple abdominal viscera thromboembolic infarcts

Case contributed by Dr Bruno Di Muzio

Presentation

Patient in IUCU post extensive vascular surgery to abdominal aorta repair due to a mycotic aneurysm (MSSA bacteremia).

Patient Data

Age: 70 years
Gender: Female
CT

CTA Abdomen and pelvis (selected images)

Thoracic aorta graft involving the arch and proximal descending segments with a residual aneurysm arising from the left aspect of the aortic arch. No evidence of endoleak. Retro-oesophageal and retrotracheal bypass graft communicating the right external carotid artery to the left common carotid and subclavian arteries. The graft within the distal descending aorta until just before the coeliac trunk now contains partially occlusive eccentric thrombus located anteriorly, measuring approximately 6.6cm in length. No evidence of endoleak. There has been the correction of the focal aneurysmal dilatation of the abdominal aorta at the level of the superior mesenteric artery. 

The origin of the coeliac trunk, SMA, and renal arteries are capacious and opacify normally. Circumferential non-significant narrowing is now seen at the distal aspect of the distal aortic anastomosis with further infrarenal atheromatous calcification extending into the common iliac arteries. Central arterial line placed in the left common femoral artery. Portal vein, superior mesenteric vein, and inferior vena cava appear patent. Central venous line within the left common femoral vein. 

Multiple ill-defined areas of low attenuation scattered through the periphery of the liver and spleen parenchyma are likely regions of infarction. The right kidney is oedematous and shows only patchy medullary and thin capsular enhancement consistent with a diffuse infarct. Similar focal infarct appearances noted within the left kidney inferior moiety. Patchy infarcts also pointed out in both adrenal glands. The bowel is not dilated and has normal wall enhancement. Small amount of free intraperitoneal fluid. Pneumoperitoneum is likely related to the recent surgery. Bilateral pleural effusions and partial lower lobes collapse with superimposed consolidation at the right base and patchy infiltrates right upper lobe laterally. The endotracheal tube is a good position. Airways are unremarkable. The nasogastric tube in situ. 

Multiple segmental/subsegmental occlusive and non-occlusive pulmonary emboli within the right lower lobe and small volume non-occlusive PEs in the right upper lobe. No radiological features of right heart strain. Some of the patchy consolidation in the right lower lobe may reflect pulmonary haemorrhage secondary to PE in the correct clinical context. Infarction is felt less likely.

Case Discussion

This is a busy CT scan with a lot of things going on, but the most interest findings are the multiple visceral infarcts involving the liver, spleen, adrenal glands, and both kidneys that are likely thromboembolic sequelae in this clinical context. 

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Case information

rID: 53106
Case created: 1st May 2017
Last edited: 15th Oct 2017
System: Vascular
Inclusion in quiz mode: Included

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