Methods
Focused Assessment With Sonography in Trauma (FAST) was performed and there was evidence of minimal to mild perisplenic, perihepatic and Morrison’s fluid. After establishing stable conditions, the patient underwent imaging workup. In the graphs, there was evidence of a fracture of the pubic ramus on the right side and the right calcaneus bone. There was no pathological point in the Computed Tomography (CT) without contrast of the brain and neck. In chest CT with contrast, there was evidence of outpouching of the anterior inner wall of the descending aorta at the level of ligamentum arteriosum measuring 19x11 mm. In the abdominal CT with contrast, there was evidence of nomortroperitoneum around the second part of the duodenum and subhepatic area. In addition, partial laceration with hematoma was evident in the spleen and mild perisplenic fluid. There was mild interloop fluid in the abdomen and pelvis. Also, the fracture of the pubic ramus on the right side and the surrounding soft tissue hematoma were evident.
Due to the absence of symptoms of peritonitis, we decided to repair the aorta at this stage. The patient was a candidate for TEVAR. Digital angiography of the descending thoracic aorta and aortic arch was performed under general anesthesia, and the diagnosis of BTAI grade III of the descending aorta after the left subclavian location was confirmed (Fig. 1). After inserting the F6 pigtail, in the right common femoral artery to ascending aorta, the hydrophilic guide wire was advanced to the aortic arch, and the wire was replaced with Lunderquist ® Wire (Fig. 2). The Zenith Alpha stent was released in the right place under X-ray positioning. Control arterial angiography was normal. Next, the femoral artery was repaired (Fig. 3).
After performing TEVAR, the patient was transferred to the intensive care unit and was monitored for 12 hours. During this interval, the clinical condition of the patient was stable. Later, the patient was a candidate for exploratory laparotomy. On examination of the abdominal cavity, there was evidence of brief fluid and partial splenic hematoma. Stomach and liver had no pathological findings. From the ligament of Trietz to the ileocecal valve and then to the rectum, there was no significant point. There was a hematoma and minimal bile discharge around the duodenum and subhepatic area. In further investigation, there was a 1 cm perforation on the lateral wall of the second part of the duodenum, which was initially repaired by simple suture. The omental flap was placed on the repair site. A gastrojejunostomy was performed to protect the repair. After making sure that there was no damage in other parts of the abdomen, the surgery was ended. Five days after the surgery and after ensuring recovery, the patient was transferred to the orthopedic service to continue the treatment. In the follow-up 3 months after the surgery, the patient did not complain.