\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Point-of-Care Ultrasound for Identification of Ruptured Infrarenal
Abdominal Aortic Aneurysm}



\author[1]{Anne Kelly Rhudy}%
\author[1]{Shivik Patel}%
\author[1]{Alex Houser}%
\author[1]{Malachi Sheahan}%
\affil[1]{LSU Health New Orleans}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Ruptured abdominal aortic aneurysms are associated with high mortality
rates and require prompt diagnosis with subsequent intervention. CT scan
is considered the gold-standard for diagnosis, however, in the acute
setting ultrasound may be a reasonable diagnostic test for certain
patients. We report a case that demonstrates the utility of bedside
ultrasound of rAAA for a patient in extremis. Also, we provide a brief
review of literature for the diagnosis of rAAA with ultrasound.%
\end{abstract}%



\sloppy


\textbf{Title}

Point-of-Care Ultrasound for Identification of Ruptured Infrarenal
Abdominal Aortic Aneurysm

\textbf{Authors}

Anne Kelly Rhudy MD MPH,

Division of Vascular Surgery, Louisiana State University Health
Sciences, New Orleans, LA

Shivik Patel MD

Division of Vascular Surgery, Louisiana State University Health
Sciences, New Orleans, LA

Alex Houser BS

Division of Vascular Surgery, Louisiana State University Health
Sciences, New Orleans, LA

Malachi Sheahan MD

Division of Vascular Surgery, Louisiana State University Health
Sciences, New Orleans, LA

\textbf{Correspondence}

Anne Kelly Rhudy

Department of Surgery

LSUHSC School of Medicine

1542 Tulane Ave, 7th Floor

New Orleans, LA 70112

Email: arhudy@lsuhsc.edu

\textbf{Abstract}

Ruptured abdominal aortic aneurysms are associated with high mortality
rates and require prompt diagnosis with subsequent intervention. CT scan
is considered the gold-standard for diagnosis, however, in the acute
setting ultrasound may be a reasonable diagnostic test for certain
patients. We report a case that demonstrates the utility of bedside
ultrasound of rAAA for a patient in extremis. Also, we provide a brief
review of literature for the diagnosis of rAAA with ultrasound.

\textbf{Keywords}

ruptured infrarenal abdominal aortic aneurysm, ultrasound, point of care

\textbf{Background}

Despite major advances in surgical techniques, ruptured abdominal aortic
aneurysms a still carry high mortality. The overall mortality of
ruptured abdominal aortic aneurysm (rAAA) is approximately 70\%
including in and out of hospital deaths with approximately half dying
prior to hospital presentation.\textsuperscript{1} Surgical mortality
remains at least 40\% for those that do make it to the operating room. A
missed diagnosis of rAAA is lethal. Established poor preoperative
mortality risk factors include old age, hypotension, and elevated
creatinine at presentation. \textsuperscript{1} Our case study focuses
on a patient with known infrarenal abdominal aortic aneurysm (AAA) who
was brought into the emergency department after cardiac arrest. A
point-of-care (POC) ultrasound was obtained which confirmed rAAA.
Bedside ultrasound can be a useful diagnostic tool, especially in
patients in extremis or in those who are unable to provide a history.
Obtaining a CT scan can be difficult in hemodynamically unstable
patients and thus a POC ultrasound may be an expedient, non-invasive
tool to guide clinical decision making in the acute care setting.

\textbf{Case Report}

Patient MC was a 78-year-old female with a past medical history of
diabetes, obstructive lung disease, hypertension, cirrhosis with
esophageal varices and known AAA who presented to the emergency
department after cardiac arrest from her nursing home. She was found
unresponsive, hypoglycemic and with pulseless electrical activity.
Dextrose was given and ACLS initiated with return of spontaneous
circulation after 18 minutes. She required vasopressor support.
Ultrasound findings in the emergency department were concerning for rAAA
and vascular surgery was consulted. After discussion with family, in the
setting of the patient's cardiac arrest in the field with an unknown
anoxic time we pursued palliative options.

\textbf{Ultrasound Images}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1: Transverse view demonstrating 5.19 cm AAA at the level
of the lowest left renal artery}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2: Transverse view showing 4.4 cm AAA with periaortic
stranding along the postero-lateral wall consistent with rAAA}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 3: Transverse view with heterogenous intramural thrombus,
with disruption of retroperitoneal planes and hematoma consistent with
rAAA}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\textbf{Figure 4: Sagittal view of floating intramural hematoma with
dissection flap. Disrupted retroperitoneal tissue planes inferiorly}

\textbf{Discussion}

Without rapid intervention, rAAA carries a high mortality. Using
ultrasound assessment of patients in extremis may decrease time to the
operating room. Unfortunately, with our patient's co-morbidities and
cardiac arrest in the field she was not a candidate for surgical repair.
Nevertheless, it is important to appreciate the value of ultrasound
findings of rAAA. Catalano and Siani discussed the sonographic findings
of ruptured AAA in 2005. Their series included 29 patients with rAAA
(either confirmed via surgery or CT scan). The findings consistent with
rAAA are (1) AAA deformation, (2) Luminal thrombus inhomogeneity, (3)
Clear interruption of the lumen thrombus, (4) Intraluminal floating
thrombus layer, (5) Aneurysm wall interruption, (6) Para-aortic
hypoechoic area adjacent to bleeding site, (7) Retroperitoneal hematoma,
and (8) Hemoperitoneum.\textsuperscript{2} All of these signs, excluding
AAA deformation, were noted in rAAA. There is discussion as to whether
with improved sonographic technology, in the hands of an experienced
user, if ultrasound could replace the need for pre-operative CT
angiograms, especially in hemodynamically unstable patients.

Perioperative hypotension is a negative survival predictor for rAAA;
therefore, delays in diagnosis, can increase time to operative repair
and prolong hypotensive time. In 2014, Reed and Cheung studied the
effect of an emergency ultrasound program to expedite time to diagnosis.
Although their study may have been underpowered for statistical
significance, there was an overall decrease in time to diagnosis (56
minutes vs 111 minutes).\textsuperscript{3} This is an area of further
inquiry in the current literature. Excluding technical considerations, a
drawback of ultrasound can be the difficulty in assessing relevant
visceral and renal artery anatomy for endovascular. Although a
significant portion of open AAA repairs will require supraceliac
clamping, it can be more difficult to assess distal targets such as
iliac artery involvement.\textsuperscript{4} With ultrasound being
increasingly employed for diagnosing of complex and urgent pathology,
future studies are needed to address its use for pre-operative planning
in the acute setting.

Within the current literature, more comparative studies need to be
performed before ultrasound can replace CT angiogram as diagnostic gold
standard for rAAA. Nevertheless, POC ultrasound facilitates swift
clinical decision making for immediate patient care, with the added
benefit of lower cost.

\textbf{References}

{[}1{]} Hoornweg LL, Storm-Versloot MN, Ubbink DT, Koelemay MJW,
Legemate DA, Balm R. Meta-analysis on mortality of ruptured abdominal
aortic aneurysms. European journal of vascular and endovascular surgery:
the official journal of the European Society for Vascular Surgery.
2008;35(5):558-570.

{[}2{]} Catalano O, Siani A. Ruptured abdominal aortic aneurysm:
categorization of sonographic findings and report of 3 new signs.
Journal of ultrasound in medicine: official journal of the American
Institute of Ultrasound in Medicine. 2005;24(8):1077-1083.

{[}3{]} Reed MJ, Cheung L-T. Emergency department led emergency
ultrasound may improve the time to diagnosis in patients presenting with
a ruptured abdominal aortic aneurysm. European journal of emergency
medicine: official journal of the European Society for Emergency
Medicine. 2014;21(4):272-275.

{[}4{]} El-Sabrout RA, Reul GJ. Suprarenal or supraceliac aortic
clamping during repair of infrarenal abdominal aortic aneurysms. Tex
Heart Inst J. 2001;28(4):254-264.

\textbf{Figure Legends}

Figure 1: Transverse view demonstrating 5.19 cm AAA at the level of the
lowest left renal artery

Figure 2: Transverse view showing 4.4 cm AAA with periaortic stranding
along the postero-lateral wall consistent with rAAA

Figure 3: Transverse view with heterogenous intramural thrombus, with
disruption of retroperitoneal planes and hematoma consistent with rAAA

Figure 4: Sagittal view of floating intramural hematoma with dissection
flap. Disrupted retroperitoneal tissue planes inferiorly

\textbf{Data Availability Statement}

The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to containing information that could compromise the
privacy of patients.

\selectlanguage{english}
\FloatBarrier
\end{document}

