Case Presentation:

Ms. P was frustrated after her neurosurgeon cancelled a scheduled lumbar laminectomy to correct her spinal stenosis. The surgeon had concluded this 73–year–old woman was a prohibitive surgical risk due to hypertension, COPD due to 75 pack year smoking history, coronary disease, and recent aortic aneurysm repair. She presented to our ED with worsening lower back pain and new numbness and tingling from the waist down, accompanied by bowel and bladder incontinence. Her chief complaint was “I’m here for surgery”. In the emergency department she underwent an MRI of the spine demonstrating only moderate L2/3 spinal stenosis. Our neurosurgical consultant concluded that she did not require surgery. This doubly frustrated patient was admitted to the Internal Medicine service for management. Neurology recommended numerous studies. CSF was unremarkable. CT myelogram demonstrated no compression. EMG demonstrated a nonspecific lumbar radiculopathy with minimal ongoing denervation. On Hospital Day 3 neurosurgery and neurology signed off, recommending referral to rehab. Review of the history and evaluation were discussed between hospitalists, an alternative diagnosis entertained, and a diagnostic procedure performed. See Figure 1. CT angiogram revealing malposition of a Zenith (Cooke) endovascular stent in the infrarenal aorta with a large endoleak comprising most of the 6.8 cm aneurysmal sac with thrombosis of the bilateral iliac arteries. The patient underwent urgent open surgical repair of the aorta and thrombosed iliac arteries. She was discharged to rehab with complete resolution of her neurologic symptoms.

Discussion:

Hospitalists often care for complicated medical patients including those with abdominal aortic pathology. Endovascular stents (EVARs) are increasingly used for repair of abdominal aortic aneurysm. When compared to open repair, EVARs result in a short–term decrease in 30–day mortality (1.8% vs. 4.3%). However, there is an increased need for reintervention without overall mortality benefit in patients followed for up to 8 years. In one study, 48.7 % of EVAR complications occurred in the first 6 months. Our patient was 5 months post–procedure. Complications can include endoleak with or without thrombosis, stent migration or rupture. Aortic pathology can manifest in a wide variety of neurologic symptoms even without pain.

Conclusions:

1. Patients with aortic disease may present with neurologic complaints. 2. Endovascular stents are used with increasing frequency, and the astute hospitalist should recognize signs and symptoms of post–procedural complications.

Figure 1CT Angiogram.