S imple rib fractures are the most common injury sustained following blunt chest trauma, accounting for more than half of the thoracic injuries that result from nonpenetrating trauma. Approximately 10% of all patients admitted after blunt chest trauma have one or more rib fractures. These fractures are rarely life-threatening but can be an external marker of severe visceral injury inside the abdomen and the chest. First-rib fractures are considered to be an indicator of increased morbidity and mortality in major trauma. According to one study from the UK Trauma Audit and Research Network, a first-rib fracture is a significant predictor of injury severity (Injury Severity Score >15) and polytrauma. Multiple rib fractures are very common in patients with thoracic trauma and are associated with significant morbidity and mortality rates especially in patients with flail chest injuries. 1 A flail chest injury is defined as at least three adjacent ribs fracturing in which there are fractures in at least two places. Flail chest injury presents with paradoxical movement of the chest wall that leads to inadequate breathing and ventilation, pulmonary dysfunction, and potential lung infection. 1-3 The reported mortality rate in flail chest injury is about 10-33% 1,2. Multiple rib fractures can lead to respiratory insufficiency due to pulmonary contusion, intrathoracic organ injuries, and severe pain with chest wall movement. Respiratory insufficiency can lead to significant morbidity and mortality rates. 2,4,5 Conservative treatment of multiple rib fractures is a standard treatment that consists of acute pain management such as analgesic medication and intercostal nerve block, 6 a mechanical ventilator and pulmonary hygiene. However, in some patients, conservative treatment may result in a prolonged intensive care units (ICU) stay, pulmonary complications or prolonged intubation. 6,10 A recent meta-analysis showed rib fixation for flail chest can reduce mortality, lead to a shorter hospital stay, and lower incidences of pneumonia and the need for a tracheostomy compared to non-operative treatments. 7,8 However, there was insufficient data supporting rib fixation in cases of multiple rib fractures without a flail segment.
uxtarenal aortic aneurysms (JRA) account for approximately 15% of abdominal aortic aneurysms. 1 By definition, suprarenal aortic crossclamping is required for surgical repair, causing temporary renal artery occlusion that may lead to postoperative renal dysfunction, in some case requiring (temporary) hemodialysis. Standard endovascular aneurysm repair (EVAR) is not an option due to inadequate landing zone for the graft below the renal vessels. Hence fenestrated and branched aortic endografts have been developed to treat high risk patients unfit for open surgery and anatomically unsuitable for standard EVAR. However, procedures are complex, technically challenging, and time consuming. 2,3 Case Report A 74-year-old man with a past medical history of hypertension, dyslipidemia, ischemic heart disease, chronic renal insufficiency and peripheral vascular disease, underwent right total knee replacement in March 2018. Postoperative kidney ultrasonography was performed due to renal insufficiency which revealed an abdominal aortic aneurysm. His computed tomography (CT) scan of the thorax, abdomen, and pelvis showed a large pararenal abdominal aortic aneurysm (7.8x6.8 cm) (Figure 1).
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