Coagulopathy in Ruptured or Dissecting Aortic Aneurysms
JAN W. ten CATE, M.D. HUGO TIMMERS. M.D. ANTON E. BECKER, M.D. Amsterdam. The Netherlands
A consumption coagulopathy was demonstrated in each of four patients with etther ruptured aneurysm of the aorta or a dissecting aorttc aneurysm. The most prominent features of this disorder were (1) a prolonged prothrombin time due to a decrease of one or more clotting factors, and (2) formation of fibrin and fibrinogen degradation products. Recognition of this coagulation disorder could be a valuable diagnostic tool to differentiate a ruptured or dissecting aortic aneurysm from other conditions with a similar acute onset. The coagulation disorder could be due to liberation of coagulant material from the aortic wall into the circulation or to an accumulation of clotting factors at the site of the lesion, secondary to the local exposition of tissue factors from the torn arterial wall. The probability of the latter mechanism is suggested by the local increase of radioactivity after the injectlon of 1251-fibrlnogen. The accurate and instant diagnosis of a ruptured or dissecting aortic aneurysm can be of vital importance for the ultimate prognosis. Various clinical methods are applied, of which angiography and, more recently, echoangiography are well established. However, extensive clot formation accompanying this process could lead to an additional diagnostic approach, since consumption coagulopathy could then be expected to occur. Nonetheless, only three patients with a ruptured arterial aneurysm in whom a consumption of platelets and fibrinogen had resulted in a hemorrhagic diathesis have thus far been well documented [ 11. In other reports, only occasional mention is made of an accompanying coagulation disorder [241. The recent studies of Straub and Kessler [ 51 do indeed suggest that local deposition of fibrinogen at the site of the aneurysm plays an important role in causing a clotting disorder. Our study was initiated by the discovery of an unexpected high level of fibrin and fibrinogen degradation products in a patient with a dissecting aneurysm of the ascending aorta. This finding was confirmed and further elaborated on in a subsequent series of four patients, three of whom were suffering from a dissecting aneurysm and one from a ruptured atherosclerotic aneurysm. These studies provide evidence that profound disturbances in the intrinsic and extrinsic coagulation profile may accompany rupture of an aortic aneurysm.
From the Departments of Internal Medicine and Pathological Anatomy, University of Amsterdam, Wilhelmina Gasthuis, Amsterdam, The Netherlands. Requests for reprints shoukf be addressed to Dr. Anton E. Becker, Department of Pathology, Wilhelmina Gasthuis, Amsterdam, The Netherlands. Manuscript accepted November 2. 1974.
MATERIALS AND METHODS Venous blood samples for coagulation studies .were collected
in plastic
tubes. Nine volumes of blood were anticoagulated with one volume of 3.2
per cent trisodium citrate dihydrate. Plasma was obtained after centrifugation for 15 minutes at 1,700 g at room temperature and made platelet poor by a second run at 20,000 g in a Sorvall RC-PB centrifuge for 30 August 1975
The Amerkan Journalol Medicine
Volume 59
171
COAGULOPATHY
TABLE I
IN AORTIC ANEURYSMS-ten
Results of Coagulation
CATE ET AL
Studies
Case3 Method Thrombotest (%) Prothrombin time (set) Factor II (%) Factor V (%) Factor VI I (%) Factor X (%) Factor VIII (%) Factor VIII-RA(“/o) Factor IX (%) Factor Xl (%) Factor XII (%) PIVKA (U) Fibrinogen (mg/lOO ml) Fibrin/fibrinogen degradation products(mg/lOO ml) Ethanol gelation test Plasminogen (U) Platelet count (X103/mm8)
Case1
17.5 80 42 69 79
... 30 32 ... 39
0
... ... ... ... ... ...
52 4 Negative
325 10 Positive
...
...
...
38
80
The American Journal of Medlclne
On Admittance 108 13.4 103 43 138 123 46 160 83 84 49 0 107 28 Positive 3.9 191
8 Hours
Later
... 13.8 82 58 84 80 24 167 65 90 51
... 120 22 Positive 4.0 148
Case4
... 15 63 62 67 55 115 108 82 91 24 0 194 22 Positive 1.1 160
Normal Values 70-130 11.2-13.0 70-140 80-140 70-140 70-140 50-150 40-150 50-150 50-150 50-150 0 176-350
JAN W. ten CATE, M.D. HUGO TIMMERS. M.D. ANTON E. BECKER, M.D. Amsterdam. The Netherlands
A consumption coagulopathy was demonstrated in each of four patients with etther ruptured aneurysm of the aorta or a dissecting aorttc aneurysm. The most prominent features of this disorder were (1) a prolonged prothrombin time due to a decrease of one or more clotting factors, and (2) formation of fibrin and fibrinogen degradation products. Recognition of this coagulation disorder could be a valuable diagnostic tool to differentiate a ruptured or dissecting aortic aneurysm from other conditions with a similar acute onset. The coagulation disorder could be due to liberation of coagulant material from the aortic wall into the circulation or to an accumulation of clotting factors at the site of the lesion, secondary to the local exposition of tissue factors from the torn arterial wall. The probability of the latter mechanism is suggested by the local increase of radioactivity after the injectlon of 1251-fibrlnogen. The accurate and instant diagnosis of a ruptured or dissecting aortic aneurysm can be of vital importance for the ultimate prognosis. Various clinical methods are applied, of which angiography and, more recently, echoangiography are well established. However, extensive clot formation accompanying this process could lead to an additional diagnostic approach, since consumption coagulopathy could then be expected to occur. Nonetheless, only three patients with a ruptured arterial aneurysm in whom a consumption of platelets and fibrinogen had resulted in a hemorrhagic diathesis have thus far been well documented [ 11. In other reports, only occasional mention is made of an accompanying coagulation disorder [241. The recent studies of Straub and Kessler [ 51 do indeed suggest that local deposition of fibrinogen at the site of the aneurysm plays an important role in causing a clotting disorder. Our study was initiated by the discovery of an unexpected high level of fibrin and fibrinogen degradation products in a patient with a dissecting aneurysm of the ascending aorta. This finding was confirmed and further elaborated on in a subsequent series of four patients, three of whom were suffering from a dissecting aneurysm and one from a ruptured atherosclerotic aneurysm. These studies provide evidence that profound disturbances in the intrinsic and extrinsic coagulation profile may accompany rupture of an aortic aneurysm.
From the Departments of Internal Medicine and Pathological Anatomy, University of Amsterdam, Wilhelmina Gasthuis, Amsterdam, The Netherlands. Requests for reprints shoukf be addressed to Dr. Anton E. Becker, Department of Pathology, Wilhelmina Gasthuis, Amsterdam, The Netherlands. Manuscript accepted November 2. 1974.
MATERIALS AND METHODS Venous blood samples for coagulation studies .were collected
in plastic
tubes. Nine volumes of blood were anticoagulated with one volume of 3.2
per cent trisodium citrate dihydrate. Plasma was obtained after centrifugation for 15 minutes at 1,700 g at room temperature and made platelet poor by a second run at 20,000 g in a Sorvall RC-PB centrifuge for 30 August 1975
The Amerkan Journalol Medicine
Volume 59
171
COAGULOPATHY
TABLE I
IN AORTIC ANEURYSMS-ten
Results of Coagulation
CATE ET AL
Studies
Case3 Method Thrombotest (%) Prothrombin time (set) Factor II (%) Factor V (%) Factor VI I (%) Factor X (%) Factor VIII (%) Factor VIII-RA(“/o) Factor IX (%) Factor Xl (%) Factor XII (%) PIVKA (U) Fibrinogen (mg/lOO ml) Fibrin/fibrinogen degradation products(mg/lOO ml) Ethanol gelation test Plasminogen (U) Platelet count (X103/mm8)
Case1
17.5 80 42 69 79
... 30 32 ... 39
0
... ... ... ... ... ...
52 4 Negative
325 10 Positive
...
...
...
38
80
The American Journal of Medlclne
On Admittance 108 13.4 103 43 138 123 46 160 83 84 49 0 107 28 Positive 3.9 191
8 Hours
Later
... 13.8 82 58 84 80 24 167 65 90 51
... 120 22 Positive 4.0 148
Case4
... 15 63 62 67 55 115 108 82 91 24 0 194 22 Positive 1.1 160
Normal Values 70-130 11.2-13.0 70-140 80-140 70-140 70-140 50-150 40-150 50-150 50-150 50-150 0 176-350
