When hematuria becomes life-threatening

Ruptured abdominal aortic aneurysm (AAA) is a life-threatening condition requiring rapid diagnosis and urgent management.

In rare cases, it may present with atypical symptoms such as gross hematuria, particularly when complicated by an aortorenal fistula.

This case highlights the diagnostic challenge of an unusual presentation of hemorrhagic shock and emphasises the importance of prompt imaging and decision-making in the emergency setting.

Jaroen Cheewinmethasiri

Lampang hospital, Thailand

Part I - Case presentation

Clinical presentation

A 72-year-old man presented with syncope while watching television. Shortly beforehand, he noticed that his underwear had become wet and realised he had experienced an episode of urinary incontinence. The urine was grossly bloody, prompting immediate transfer to the emergency department.

On arrival, he was hemodynamically unstable, with a blood pressure of 40/20 mmHg and a heart rate of 140 bpm. Physical examination revealed a palpable pulsatile abdominal mass measuring approximately 5 cm.

Bedside ultrasound demonstrated a 6 cm abdominal aortic aneurysm (AAA) and a large hematoma within the urinary bladder.

After initial resuscitation, the patient was transferred urgently to the CT suite. A whole-aorta CT angiography (CTA) was then performed.

Part II - Final strategy

Final strategy and diagnosis

The final diagnosis was a ruptured abdominal aortic aneurysm (AAA) with an aortorenal fistula.

Given the patient’s hemodynamic instability, an endovascular approach was selected. EVAR with an aorto-uni-iliac (AUI) configuration and femoro-femoral crossover bypass was performed. An Endurant II stent-graft AUI system was used, with a main body 23–14–102.

Procedure

Surgical bilateral common femoral artery (CFA) cutdown was performed.
During sheath insertion, the patient suffered cardiac arrest.
Immediate cardiopulmonary resuscitation (CPR) was initiated.

Procedure continuation

The main body (23–14–102) of the Endurant II stent-graft was deployed.
A contralateral limb extension (16–13–93) was deployed into the right common iliac artery.
An occlusion device (No. 14) was placed in the left common iliac artery.
A femoro-femoral crossover bypass was then performed using an 8 mm ring-reinforced PTFE graft.
The procedure was completed uneventfully.

Post-operative course

The patient remained hemodynamically stable under inotropic support; however, there was no urine output following the intraoperative cardiac arrest. On physical examination, a distended urinary bladder was palpable, raising suspicion of urinary tract obstruction due to clot retention.

Bedside ultrasound confirmed a fully distended bladder filled with blood clots, associated with severe right hydronephrosis.

A urology consultation was obtained, and cystoscopic bladder irrigation was performed with placement of a right percutaneous nephrostomy (PCN).

The patient subsequently developed acute kidney injury (serum creatinine 8.4 mg/dL) with persistent anuria. Nephrology was consulted, and renal replacement therapy was initiated with dialysis.

Renal function gradually improved, with creatinine decreasing to 1.49 mg/dL at two weeks.

The patient was discharged on post-operative day 20.

Follow up

Patient came to OPD 2 weeks after discharge.
He was doing well and his creatinine was 1.07.
6 weeks after discharge, his creatinine was 0.91.
He was sent to request CTA after nephrologist was consulted.

Conclusion

EVAR provides a safe and effective treatment strategy for ruptured AAA with favourable early results.