When patients present with life threatening conditions, a rapid cost-benefit analysis prioritizes care and commits treatment to a certain course that, in the case of ST Elevation Myocardial Infarction (STEMI) treated with drug-eluting stents (DES), could be fatal if there is any deviation. Antiplatelet therapy is vital and secondary concerns (i.e. bleeding diatheses) may accept suboptimal outcomes – in rare cases, another life-threatening condition may be unmasked, the treatment for which runs directly counter to the first. We present a case of STEMI with high clot burden treated with multiple DES, complicated by retroperitoneal hemorrhage due to a ruptured abdominal aortic aneurysm.
Conflict(s) of Interest
References with DOI
1. CDC, NCHS. Underlying Cause of Death 1999-2013 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2013, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed Feb. 3, 2015.
2. Tada T, Byrne RA, Simunovic I et al. Risk of stent thrombosis among bare-metal stents, first-generation drug-eluting stents, and second-generation drug-eluting stents: results from a registry of 18,334 Patients. J Am Coll Cardiol Intv. 2013;6(12):1267-1274. https://doi.org/10.1016/j.jcin.2013.06.015
3. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. An update of the 2011 ACC/AHA/SCAI PCI Guideline, 2011 ACC/AHA CABG Guideline, 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS SIHD Guideline, 2013 ACC/AHA STEMI Guideline, 2014 ACC/AHA NSTE-ACS Guideline, and 2014 ACC/AHA Perioperative Guideline. J Am Coll Cardiol. 2016;Mar 29. https://doi.org/10.1161/cir.0000000000000404
4. D'Ascenzo, Fabrizio et al. Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses. International journal of cardiology. 167.2 (2013): 575-584. https://doi.org/10.1016/j.ijcard.2012.01.080
5. Farouque H, Tremmel JA, Raissi Shabari F et al. Risk factors for the development of retroperitoneal hematoma after percutaneous coronary intervention in the era of glycoprotein IIb/IIIa inhibitors and vascular closure devices. J Am Coll Cardiol. 2005;45(3):363-368. doi:10.1016/j.jacc.2004.10.042. https://doi.org/10.1016/j.jacc.2004.10.042
6. Kent K. Craig et al. Retroperitoneal hematoma after cardiac catheterization: prevalence, risk factors, and optimal management. Journal of vascular surgery. 20.6 (1994): 905-913. https://doi.org/10.1016/0741-5214(94)90227-5
7. Trimarchi S, Smith DE, Share D et al. Retroperitoneal hematoma after percutaneous coronary intervention: prevalence, risk factors, management, outcomes, and predictors of mortality: a report from the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) Registry. J Am Coll Cardiol Intv. 2010;3(8):845-850. https://doi.org/10.1016/j.jcin.2010.05.013
8. Madaric Juraj et al. Frequency of abdominal aortic aneurysm in patients> 60 years of age with coronary artery disease. The American journal of cardiology. 96.9 (2005): 1214-1216. https://doi.org/10.1016/j.amjcard.2005.06.058
9. Strachan D. P. Predictors of death from aortic aneurysm among middle‐aged men: the Whitehall
study. British journal of surgery. 78.4 (1991): 401-404. https://doi.org/10.1002/bjs.1800780407
10. LeFevre Michael L. Screening for abdominal aortic aneurysm: US Preventive Services Task Force recommendation statement..Annals of internal medicine. 161.4 (2014): 281-290. https://doi.org/10.7326/m14-1204
11. Scott RAP, Bridgewater S, Ashton HA. Randomised clinical trial of screening for abdominal aortic aneurysm in women. Br J Surg. 2002; 89: 283–285.
12. Thompson RW, Curci JA, Ennis TL et al. Pathophysiology of abdominal aortic aneurysms: insights from the elastase-induced model in mice with different genetic backgrounds. Ann N Y Acad Sci 2006;1085:59–7 https://doi.org/10.1196/annals.1383.029
13. Pearce William H, Christopher K. Zarins, J. Michael Bacharach. Atherosclerotic peripheral vascular disease symposium II controversies in abdominal aortic aneurysm repair. Circulation 118.25 (2008): 2860- 2863. https://doi.org/10.1161/circulationaha.108.191176
14. Choke E et al. A review of biological factors implicated in abdominal aortic aneurysm rupture. European Journal of Vascular and Endovascular Surgery 30.3 (2005): 227-244. https://doi.org/10.1016/j.ejvs.2005.03.009
15. Eefting D et al. Ruptured AAA: state of the art management. The Journal of cardiovascular surgery 54.1 Suppl 1 (2013): 47-53.
16. Lederle Frank A et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. Jama 287.22 (2002): 2968-2972. https://doi.org/10.1001/jama.287.22.2968
Neasman, Farley B. III; Lester, Melissa D.; and Chowdhury, Nepal C.
"Inferior STEMI Complicated by Retroperitoneal Hemorrhage due to Ruptured AAA,"
Marshall Journal of Medicine:
1, Article 5.
Available at: https://mds.marshall.edu/mjm/vol3/iss1/5