Unsuspected chronic traumatic aortic pseudoaneurysm – what to do about it. Late post-traumatic aortic pseudoaneurysm

Abstract

A 59-year-old man presented to his primary care physician with complaints of precordial discomfort, which occurred one week earlier while running to catch a bus. The discomfort, described as a "heavy weight on the chest", lasted for 5 min, was unrelated to position or respiration, subsided with rest and did not recur. His prior history included hypercholesterolemia, systemic hypertension, cigarette smoking (one pack per day for 35 years) and involvement in a serious motor vehicle accident 30 years previously.An electrocardiogram performed at rest demonstrated no abnormalities. The diagnosis of new-onset effort angina pectoris was made; atenolol 50 mg daily was added to the patient's previous medication regimen, which included acetylsalicylic acid 80 mg, hydrochlorothiazide 25 mg and atorvastatin 80 mg daily. The patient was referred for cardiac catheterization. Coronary angiography demonstrated 50% diameter stenosis of the mid-left anterior descending artery and 75% diameter stenosis of a small, heavily calcified first obtuse marginal branch. An ill-defined dense area was seen during fluoroscopy in the upper mediastinum. Chest radiography was performed and showed an area of calcification in the proximal descending aortic region ( Figures 1A and 1B).The patient was referred for cardiovascular magnetic resonance imaging (CMR) for better assessment of the aortic findings. CMR demonstrated an oval-shaped structure measuring 2.5 cm × 3 cm, situated on the medial aspect of the proximal descending thoracic aorta (aortic isthmus) and connected to the aortic lumen through a narrow 'neck' -a finding consistent with an aortic pseudoaneurysm (Figures 2A, 2B and 2C). The pseudoaneurysm was situated in the aortic isthmus, opposite from the insertion point of the ligamentum arteriosus, a typical location for deceleration aortic injury (1).The patient underwent adenosine technetium-99m myocardial perfusion imaging to assess the coronary stenosis functional significance while on beta-adrenoreceptor blocker therapy. Only a small area of mild, reversible defective activity in the inferolateral region (perfused by the obtuse marginal arteries) was demonstrated. Because the patient had no further anginal symptoms, no evidence of ischemia in the left anterior descending artery territory, and because the lesion of the obtuse marginal was not suitable for percutaneous revascularization, isosorbide dinitrate (30 mg orally once daily) was added to his previous medical regimen. In consultation with the cardiothoracic surgery service, a decision was made to treat the otherwise asymptomatic aortic pseudoaneurysm medically by controlling the patient's blood pressure using beta-blockers (target systolic blood pressure of lower than 120 mmHg) and follow up with a CMR examination of the aorta in six to 12 months. A 59-year-old man with multiple risk factors for coronary artery disease who had been in a motor vehicle accident 30 years earlier presented with new-onset angina pectoris. During cardiac catheterization, an ill-defined dense area was ...

Late in-hospital rupture of a chronic post-traumatic pseudoaneurysm

“…Cervical rupture of a chronic aortic aneurysm represents a very unusual manifestation with only a handful of these cases reported in literature. [5] Similar cases have been reported in literature,[6] but what makes this case unique is that it cites a rupture of an unsuspected chronic pseudoaneurysm in a rather unusual anatomic area, which proved essential for the patient's survival.…”

Dual-phase CT for the assessment of acute vascular injuries in high-energy blunt trauma: the imaging findings and management implications

“…Chronic aortic pseudoaneurysms are detected in up to 5% of cases of undetected aortic injuries. 7,32,42 They are usually asymptomatic and can be incidentally identified on chest radiograph or CT. They can be confused for a soft-tissue mass contiguous to the aortic wall or calcified lymph node, since a calcification rim may be present.…”

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