emDOCs Podcast – Episode 104: Acute Aortic Occlusion

Background:

• AAO is a rare condition in which aortic blood flow is suddenly obstructed. May be due thrombosis or embolism; leads to potential ischemia of downstream tissue.
• Largest cohort study to date found that the mortality for AAO was 19.9% at 30 days.
• Associated with prolonged hospital stays and ⅔ of patients have complications of revascularization, including end-organ ischemia.

Epidemiology:

• Incidence7 to 5 cases per million people annually; typically impacts older adults between ages 60-70 years  with cardiovascular comorbidities.
• Thrombosis of the native aorta due to atherosclerosis is the most common underlying etiology; may also involve thrombotic occlusion of a stent, graft, or stent-graft; secondary to an abdominal aortic aneurysm; via a dissection flap; or as a result of blunt abdominal trauma.
• Embolic cases of AAO are commonly associated with atrial fibrillation; may also be due to clot formation from ventricular aneurysm, due to low ejection fraction, or valvular disease, or tumor embolism.

Pathophysiology:

• AAO most commonly occurs below the renal arteries, leading to bilateral lower extremity symptoms, though occlusion of the aorta can occur at any level.
• Embolic occlusion occurs more rapidly than thrombotic occlusion and present with more severe symptoms.

Presentation:

• Presenting symptoms of AAO relate to the organs and structures with ischemia secondary to lack of perfusion.
• Acute lower limb ischemia is the most common presentation: pain, pallor, and poikilothermia.
• Lower limb weakness is the most common reason AAO patients seek care; may be misdiagnosed as a neurologic diagnosis before a vascular issue is recognized.
• Other symptoms: back pain, GI symptoms, oliguria or anuria , myocardial infarction, or stroke.

Diagnosis:

• Exam:
  • Neurovascular: Strength, sensation, reflexes; lower extremity pulses, color (mottling, pallor, erythema, cyanosis), blisters, temperature, swelling, capillary refill.
  • Cardiovascular: Evaluate for murmurs and irregularly irregular rhythm; signs of heart failure (gallop rhythm, JVP, rales, and peripheral edema).
  • Abdomen: Presence of a pulsatile mass, tenderness.
• Testing:
  • Imaging:
    • CT angiogram of the chest, abdomen, pelvis. Highly sensitive. Determines site of occlusion, affected organs, complications.
    • MRI can be diagnostic but typically not feasible.
    • Point-of-care ultrasound (POCUS) should be performed in the unstable patient: occlusive thrombus in the aorta with absence of distal color flow in color and pulsed-wave Doppler modes
  • ECG for arrhythmia
  • CBC (leukocytosis, thrombocytopenia), coagulation panel, electrolytes, renal and liver function (AKI, liver injury), lactate (66% of patients; associated with increased mortality).

Management:

• Key components: vascular surgery consultation, anticoagulation, pain control (ideally with opioids, but consider ketamine), maintaining normoxia, fluid resuscitation if necessary, and avoiding extremes of heart rate or blood pressure.
• Volume: Target euvolemia; may require IV fluids.
• Administer blood products if patient anemic/thrombocytopenic and critically ill.
• Anticoagulation: Unfractionated heparin is the agent of choice due to its short half-life and reversibility; should be administered in all patients even in the setting of preexisting antithrombotic or antiplatelet medication use.
• Vascular surgery specialist may recommend adding a prostacyclin analog (i.e., iloprost) since this may reduce morbidity and perioperative mortality.
• Intervention:
  • Endovascular therapy with thrombo-embolectomy is commonly first-line; least invasive approach and most likely to be successful in relieving the occlusion.
  • There are a wide range of options: thrombolysis, endovascular procedures, and open procedures (e.g., aortobifemoral bypass, axillofemoral bypass, or combinations of various methods).
• Disposition: OR or endovascular suite, followed by ICU.

Summary:

• AAO is associated with high morbidity and mortality and may be due to thrombosis or embolism.
• Most commonly affects older adults with cardiovascular comorbidities.
• Typical presentation is signs and symptoms of acute limb ischemia. Neurovascular assessment is essential. Patients may also present with GI tract or renal involvement.
• Misdiagnosis leads to delays in management and increases mortality
• Imaging modality of choice is CTA of the chest, abdomen, and pelvis, but POCUS may be helpful in unstable patients.
• Management includes consulting vascular surgery specialist, administering anticoagulation, pain control, fluid resuscitate if necessary, maintain normal oxygen saturation.

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