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A 63-year-old female with a medical history of hypothyroidism and no other comorbidities. She had an episode of sudden syncope associated with epigastric pain. Assistance from the emergency services achieved recovery of full consciousness and the patient was transferred to the hospital. On arrival, the patient was hypotensive, pale and diaphoretic, and pressure was maintained by means of intravenous fluids. The physical examination revealed diffuse abdominal pain. With the clinical suspicion of internal abdominal bleeding, an urgent CT scan was performed, finding a saccular aneurysm with a maximum diameter of 36x26mm on the axial plane (VID. 1) arising from the middle third of the splenic artery. There was abundant extravasation of contrast in the arterial phase (VID. 2), which increases late phases. This was compatible with a ruptured aneurysm and the active bleeding associated with bulky diffuse hemoperitoneum.
The patient became more hypotensive and was urgently taken to the operating room. An emergency laparotomy was carried evacuating the diffuse hemoperitoneum, subsequently accessing the lesser sac. A significant hematoma was removed and the aneurysm was located. The hemorrhage was controlled by means of proximal and distal vascular clamps, after dissection of the aneurysm. Subsequent vascular resection and a splenectomy were performed.
Surgery took 140 minutes. The patient required an intraoperative poly transfusion (8 blood units, 250 ml of FPP, 1 platelet unit and 1.5gr of calcium) and vasoactive drugs. The immediate postoperative period was at the intensive care unit, with a correct evolution. Weaning off the vasoactive support was successfully accomplished on the first postoperative day. The patient remained hemodynamically stable with sustained Hb levels of 10.8 g/dl. She was transferred to a conventional room on the 5th postoperative day, tolerating the progressive reintroduction of the oral intake. Postsplenectomy vaccines and prophylactic antibiotics were administered. The patient was uneventfully discharged on the 9th postoperative day. The pathological examination revealed an aneurysmal dilation of the splenic artery with a dissected wall and a mural thrombus. No neoplasia or vasculitis were found.
