Ann Thorac Surg 1999;67:240-241
© 1999 The Society of Thoracic Surgeons
Case Reports
Chronic traumatic aortic pseudoaneurysm: resolution with observation
Adam E. Saltman, MD, PhDa,
Lars G. Svensson, MD, PhDa
a Department of Cardiothoracic Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts, USA
Accepted for publication June 18, 1998.
Address reprint requests to Dr Svensson, Department of Cardiothoracic Surgery, Lahey Hitchcock Clinic, 41 Mall Rd, Burlington, MA 01803
e-mail: (lars.g.svensson{at}lahey.org)
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Abstract
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Immediate operative repair is the most commonly recommended treatment for traumatic aortic ruptures, regardless of age or size of the lesion. We report a patient who presented with a large chronic aortic pseudoaneurysm and has been thus far managed nonoperatively with shrinkage of his lesion and no symptoms.
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Introduction
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Most aortic ruptures, including chronic traumatic ruptures of the aorta (TRAs), are believed to either remain the same size or expand with time. In fact, only about 2% of patients with TRA survive the initial 3 months after injury without operative intervention [1–3]. We present a patient with an unusual time course of a chronic TRA.
In 1992, we were sent a 43-year-old man for evaluation and management of a traumatic thoracic aortic pseudoaneurysm. In 1977 he was involved in a motorcycle accident and underwent an extensive spinal operation. He recovered well and remained in good health until 1992, when he presented to us with episodic left-sided chest pains. His history included mild hypertension, gout, and migraine headaches. He took ibuprofen daily for low back pain. Physical examination and blood chemistries were unremarkable; he was normotensive with equal extremity blood pressures. Chest radiography revealed a calcified lesion in the aortopulmonary window. Chest computed tomography showed calcification of the aortic wall with a 4 x 5-cm saccular lesion at the level of the pulmonary artery (Fig 1). He refused surgical repair, but agreed to close follow-up. By 1995, the lesion had shrunk to 3.5 x 4 cm (Fig 2). Despite continued recommendations for surgical repair, the patient elected observation. By 1997, the lesion measured 3 x 3 cm (Fig 3). He is currently asymptomatic.
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Fig 1. Computed tomography of the chest demonstrating a calcified pseudoaneurysm of the proximal descending thoracic aorta (white arrow) just cephalad to the pulmonary artery. Performed in 1992, the lesion was measured at 4 x 5 cm. There was no evidence of contrast leakage or pleural effusion.
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Fig 2. Follow-up chest computed tomography in 1995 at the same aortic level as in the previous figure. The lesion is still present (white arrow), but now measures 3.5 x 4 cm.
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Fig 3. Most recent chest computed tomography, performed in 1997, at the same level as in the previous figures. The lesion has nearly resolved (white arrow), and now measures 3 x 3 cm.
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Comment
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Pseudoaneurysms, unlike true aneurysms, are comprised of only a thin-walled blood-containing adventitial sac. If the blood within the sac clots, the pseudoaneurysm becomes a hematoma. With time, the pseudoaneurysm walls tend to calcify. Although chest radiography was suggestive of chronic rupture of the aorta with pseudoaneurysm (TRA), contrast-enhanced computed tomography clearly established the diagnosis. Because this patient was involved in a motor vehicle accident 20 years ago, blunt trauma is the most likely cause of his chronic TRA. As many as 63% of chronic TRAs, unfortunately, are asymptomatic [4].
Although plain chest radiography is a useful test for TRA [4], contrast aortography remains the gold standard. Contrast-enhanced spiral computed tomographic scanning, as used in this case report, is highly accurate and able to show both the lumen of the TRA and the surrounding hematoma. Computed tomography also better defines three-dimensional relationships between the TRA and surrounding structures, and furnishes an easily reproducible and reliable method of follow-up [5]. Magnetic resonance imaging and angiography and transesophageal echocardiography all hold promise as future diagnostic modalities.
Despite the fact that immediate operative repair remains the most widely recommended treatment for TRA, regardless of the age of the lesion or symptoms [6], the few data available that describe the natural history of chronic TRAs do not clearly support operative intervention [1–3]. Even though operation for TRA in the present era is now accompanied by low mortality and morbidity, paraplegia is the most feared complication. Of the many methods used to help reduce the incidence of paraplegia ("clamp and sew" [7], retrograde perfusion with partial or total bypass [8], or arterial shunting [6]), atrio-femoral bypass appears to be superior.
This lesion, however, is probably 20 years old, has a thickly calcified wall, and produces no symptoms at present. It is therefore unlikely that it will expand; indeed, chest computed tomography has demonstrated the unusual finding of progressive shrinkage. Follow-up from this point will continue with biannual physical examinations, computed tomographic scans, and patient reminders of the symptoms of acute pseudoaneurysm expansion. Further resolution is expected.
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References
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Abstract
Introduction
