Saccular Aortic Arch Aneurysm with Laminated Thrombus

Abstract

A 73-year-old African American male with a history of long-standing hypertension and a 50 pack/yr smoking history presented with intermittent retrosternal chest pain and a blood pressure of 230/140 mm Hg.He had a stroke 4 years ago that has left him bedridden with right-sided hemiparesis. There is a remote history of a myocardial infarct and he is known to have renal insufficiency. His chest x-ray revealed a saccular aneurysm of the arch and descending thoracic aorta (Fig. 1). Computed tomography of the chest revealed an 8x8-cm aneurysmal dilation of the aortic arch with calcification of the wall. The ascending and descending thoracic aortae appeared unremarkable (Fig. 2).Transesophageal echocardiography showed a saccular aortic arch aneurysm measuring 7.9 cm in the largest diameter with a laminated thrombus and spontaneous echo contrast indicative of a low flow state (Fig. 3). No dissection was noted. (The aneurysm size in 1995 was 4 cm, equating to a mean expansion rate of 0.8 cm/yr.) 1 No pulses were felt in either lower extremity and vascular studies revealed a 3.5-cm thrombosed infrarenal abdominal aneurysm with no distal flow. Figure 1. Chest x-ray shows a widened mediastinum and enlargement of the aortic knob.Figure 2. Computed tomography of the chest demonstrates an 8x8-cm aortic arch aneurysm with some calcification in the wall.