Infection of the abdominal aorta is rare and is almost always associated with an aneurysm. It is either hematogenous seeding of an existing aneurysm or septic embolization to the vasa vasorum and subsequent development of a mycotic aneurysm. There have been very few documented cases of aortitis in the setting of a normal-sized caliber aorta. Spontaneous rupture of a non-aneurysmal abdominal aorta due to aortitis has not been, to our knowledge, reported before.

Medical notes including detailed patient history, emergency department admission notes, medical charts, imaging, lab tests, drug charts, and follow-up notes were retrieved and studied to describe the case in detail. Written informed consent was obtained from the patient for the publication of the case.

A 70 yrs-old male patient was transferred from a rural hospital. He was septic with rigors, and leukocytosis, and had a few hours history of acute abdominal pain radiating to the back. The working diagnosis was pyelonephritis as the patient had been pyrexic for a few days and was being treated for a urinary tract infection. CT angiogram revealed a contained rupture of normal-sized caliber infrarenal aorta. The patient was urgently operated on. Through a midline incision, the retroperitoneal space was accessed. The site of rupture was identified. There was significant inflammation but no active bleeding as a loop of the duodenum had tightly adhered to the aortic wall containing the rupture. Control of the aorta was obtained proximally at an infrarenal level and distally at the aortic bifurcation. The femoral vein was harvested from the patient's right thigh leaving the deep femoral vein intact. The aorta was cross-clamped. As it was deemed impossible to detach the adhered duodenum from the aorta without risking bowel injury, the anterior wall was resected and left on the duodenum (Image 1). The aortic wall was further debrided and sent for histology and microbiology testing. The aorta was reconstructed by end-to-end anastomoses with the reversed femoral vein graft (Image 2) and covered with an omental patch. The patient made an excellent and uneventful recovery. E. Coli which was susceptible to a variety of oral and IV antibiotics was identified at the aortic wall culture. The patient received a two weeks course of IV antibiotics and was discharged on oral antibiotics for 6 months. At his 18month follow-up, the patient remained asymptomatic and did not report any operation-related complications apart from moderate edema of the right limb that had the femoral vein harvested.

Infectious aortitis can rarely lead to rupture of the non-aneurysmal abdominal aorta. The gold-standard management is in situ reconstruction with an autologous venous graft. It is technically demanding but offers excellent short and long-term clinical results.