Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 4  |  Page : 286-288

Palpable thoracoabdominal aortic aneurysm through the chest wall: A late and ominous presentation


Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Sreekumar Ramachandran
Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_35_18

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  Abstract 


Thoracoabdominal/thoracic aortic aneurysm is often diagnosed incidentally while evaluating for dyspnea or atypical chest pain of long duration. Late presentation in various forms such as palpable pulsatile swelling in this patient is quite rare and fatal and foreruns impending rupture. We present a 53-year-old female who presented with acute-onset left-sided chest and back pain with swelling on the left side of the chest wall for 2 weeks. She was evaluated with chest X-ray which showed mediastinal widening and computed tomography scan thorax showed a large thoracic aortic aneurysm protruding out through seventh intercostal space onto the chest wall. She underwent open repair of aneurysm and was doing well at 6 months of follow-up. Thoracic aortic aneurysm mandates early diagnosis and prompt treatment as delay in the same leads to fatal rupture. Open surgical repair is the treatment of choice in large aneurysms causing significant compressive symptoms and imminent rupture.

Keywords: Open repair, rupture, thoracic aortic aneurysm


How to cite this article:
Nair HR, Pitchai S, Ramachandran S. Palpable thoracoabdominal aortic aneurysm through the chest wall: A late and ominous presentation. Indian J Vasc Endovasc Surg 2018;5:286-8

How to cite this URL:
Nair HR, Pitchai S, Ramachandran S. Palpable thoracoabdominal aortic aneurysm through the chest wall: A late and ominous presentation. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2019 Mar 18];5:286-8. Available from: http://www.indjvascsurg.org/text.asp?2018/5/4/286/247260




  Introduction Top


Thoracic/thoracoabdominal aortic aneurysms are often asymptomatic. They commonly present with chronic chest pain, dyspnea, and cough or rarely due to compressive symptoms such as esophageal or bronchial compression. Pulsatile swelling over chest wall may be due to arteriovenous malformation or cardiomegaly causing palpable apex beat, especially in lean individuals. A thoracic aortic aneurysm protruding onto the chest wall is ominous and shows the sheer size of an aneurysm and more importantly imminent spontaneous rupture.

We present the case of 53-year-old female who presented with a palpable thoracic aortic aneurysm, a presentation which is quite rare and challenging to tackle.


  Case Report Top


A 53-year-old female presented to the outpatient department with complaints of left-sided chest and upper back pain and worsening breathlessness for 2 weeks. She had undergone Bentall's procedure for ascending aortic aneurysm 14 years back and was on oral anticoagulant. Clinical examination revealed tachycardia and orthopnea. She had a tense palpable pulsatile swelling in the left seventh intercostal space of about 4 cm × 4 cm in size. Chest X-ray showed mediastinal widening. Routine blood investigations were within normal limits. Computed tomography (CT) thorax (aortogram) revealed large thoracic aortic aneurysm [Figure 1]a,[Figure 1]b,[Figure 1]c measuring 9.6 cm in maximum dimension, protruding onto the chest wall through the left seventh intercostal space. The abdominal aortic segment was healthy although ectatic (3.2-cm maximum diameter) until the origin of renal arteries. There was no evidence of rupture. There was considerable compression on the left main bronchus causing lower lobe collapse. Her echocardiogram showed normal left ventricular systolic function and functioning prosthetic valve with severe pulmonary hypertension (compression on the left main pulmonary artery). Coronary angiogram was normal. Preoperatively, she was started on low-molecular-weight heparin after stopping oral anticoagulation.
Figure 1: Axial (a) and sagittal (b) sections of computed tomography aortogram showing large descending thoracic aortic aneurysm protruding onto the left lateral chest wall through seventh intercostal space; (c) three-dimensional reconstructed computed tomography image showing ectatic origins of innominate and left subclavian arteries

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Under general anesthesia, cerebrospinal fluid (CSF) drain was inserted and prophylactically 15 ml of CSF was drained, and pressure was continuously monitored and maintained at <10 cm of H2O. If pressure was high, CSF was drained in aliquots of maximum 10–15 ml/h. Left thoracophrenolaparotomy was performed and thoracic cavity entered through fourth intercostal space. Left lung was deflated and retracted and diaphragm was divided and aorta was exposed. Surgical findings included large thoracic aneurysm (9.5 cm maximum size) arising at the base of the left subclavian artery (SCA) [Figure 2]a until the celiac trunk. Innominate artery and left SCA origins were ectatic. Proximal clamp space was created proximal to the left SCA after preserving left recurrent laryngeal nerve and vagus nerve. Distal clamp space was created above the celiac trunk. Left femoral artery was exposed for cannulation. After heparinization (2 mg/kg), proximal and distal clamps were applied and aneurysm was opened and thrombus removed. There was no backbleeding from intercostal arteries. Proximal anastomosis was done distal to the left SCA origin with 28-mm coated polyester (Intergard™ Knitted, Maquet, Germany) tubular graft [Figure 2]b. Anastomosis was checked and temporary aortofemoral bypass was established by cannulating the graft distal to anastomosis using 20F cannula (EOPA, Medtronic™) and 16F cannula into the femoral artery. Distally, anastomosis was fashioned above the celiac artery as the aorta was healthy. After checking anastomosis, aortofemoral bypass was clamped and decannulated. Adequate heparin reversal was given with protamine.
Figure 2: Intraoperative picture (a) shows large aneurysmal sac and (b) shows 28-mm coated polyester graft after anastomosis

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She had an uneventful postoperative recovery. CSF drain was removed after 48 h. She was restarted on oral anticoagulation and was discharged in hemodynamically stable condition on the 9th postoperative day. At 6 months, she was doing well and was symptom free. CT aortogram revealed intact anastomoses [Figure 3]a and [Figure 3]b.
Figure 3: Follow-up computed tomography aortogram (three-dimensional reconstructed) images (a and b) at 6 months show intact proximal and distal anastomoses

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  Discussion Top


Late presentation of the thoracic aortic aneurysm is often due to compressive symptoms such as dyspnea, dysphagia,[1],[2] or elevation of hemidiaphragm. Thoracic aortic aneurysms are largely asymptomatic. Acute expansion of the aneurysm causes interscapular pain, left-sided chest pain, and severe dyspnea.[3] Palpable thoracic aortic aneurysm has not been reported in the literature to the best of our knowledge. Large aneurysm is fatal as it can cause spontaneous rupture[4] which is often fatal.

Patients presenting with isolated chest discomfort and breathlessness present to the local physicians and diagnosis gets delayed due to lack of suspicion. Thoracic aortic aneurysms should be promptly managed with open surgical repair[5] or thoracic endovascular aortic repair (TEVAR). However, large aneurysms causing significant compression are best managed by open surgical repair[6] in a fit patient as TEVAR does not cause immediate relief of symptoms. In our index case, the aneurysm was compressing the left main bronchus, and TEVAR could not have produced relief of bronchial compression readily.


  Conclusion Top


Morbidity and mortality associated with large thoracic aortic aneurysms are high, especially when it presents like in our index patient which predisposes to imminent rupture and death. We suggest there should be high suspicion for early diagnosis and treatment of thoracic aortic aneurysm in patients presenting with atypical presentation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jovancević L, Jović R, Mitrović SM. Dysphagia aortica – Case report. Med Pregl 2005;58:401-4.  Back to cited text no. 1
    
2.
Pitchai S, Unnikrishnan M. Dysphagia aortica: Diagnostic dilemma and therapeutic paradigm. Indian J Vasc Endovasc Surg 2016;3:45-8.  Back to cited text no. 2
  [Full text]  
3.
Ghera P, Hayes D Jr. Rare cause of dyspnea: Yin-yang thoracic aortic aneurysm. Lung 2014;192:335-7.  Back to cited text no. 3
    
4.
Elefteriades JA. Natural history of thoracic aortic aneurysms: Indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg 2002;74:S1877-80.  Back to cited text no. 4
    
5.
Chiesa R, Tshomba Y, Civilini E, Marone EM, Bertoglio L, Baccellieri D, et al. Open repair of descending thoracic aneurysms. HSR Proc Intensive Care Cardiovasc Anesth 2010;2:177-90.  Back to cited text no. 5
    
6.
Katsumata T, Shinfeld A, Westaby S. Operation for chronic traumatic aortic aneurysm: When and how? Ann Thorac Surg 1998;66:774-8.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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