Atheroembolization and potential air embolization during aortic declamping in open repair of a pararenal aortic aneurysm: A case report.
BACKGROUND
When ischemic events ascribable to microembolization occur during open repair of proximal abdominal aortic aneurysms, a likely origin of atheroembolism is not always found.


METHODS
A 78-year old man with enlargement of the entire aorta underwent open repair for a pararenal abdominal aortic aneurysm using supraceliac aortic clamping for 20min. Then the graft was clamped, the supraceliac clamp was removed, and the distal and right renal anastomoses were also completed. The patient was stable throughout the operation with only transient drop in blood pressure on reperfusion. Postoperatively the patient developed ischemia, attributable to microembolization, in legs, small intestine, gall bladder and kidneys. He underwent fasciotomy, small bowel and gall bladder resections. Intestinal absorptive function did not recover adequately and he died after 4 months. Microscopic examination of hundreds of intestinal, juxtaintestinal mesenteric, and gall bladder arteries showed a few ones containing cholesterol emboli.


CONCLUSIONS
It is unsure whether a few occluded small arteries out of several hundred could have caused the ischemic injury alone. There had been only moderate backbleeding from aortic branches above the proximal anastomosis while it was sutured. Inadvertently, remaining air in the graft, aorta, and aortic branches may have been whipped into the pulsating blood, resulting in air microbubbles, when the aortic clamp was removed.


CONCLUSIONS
Although both atheromatous particles and air microbubbles are well-known causes of iatrogenic microembolization, the importance of air microembolization in open repair of pararenal aortic aneurysms is not known and need to be studied.
Department of Vascular Surgery, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway. Electronic address: eidreg@yahoo.com.
Einar Børre
EB
Dregelid
Department of Pathology, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway; The Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Haukeland University Hospital, 5021 Bergen, Norway. Electronic address: peer.lilleng@helse-bergen.no.
Peer Kåre
PK
Lilleng
Abdominal aortic aneurysm; Air embolism; Cholesterol embolism; Perioperative complication; Surgery